Coverage Overview
Questions About Part D Prescription Drug Coverage
What is Medicare prescription drug coverage (Part D)?
Medicare prescription drug coverage is insurance that covers both brand-name and
generic prescription drugs at participating pharmacies in your area. Medicare prescription
drug coverage provides protection for people who have very high drug costs.
Who can get Medicare prescription drug coverage?
Everyone with Medicare is eligible for this coverage regardless of income and resources,
health status or current prescription expenses.
When can I get Medicare prescription drug coverage?
If you are new to Medicare or have lost creditable prescription drug coverage (like
that provided by some employer or union plans) you may be eligible to enroll. Otherwise,
each year during the Annual Enrollment Period from October 15 to December 7 you
can switch to a different Medicare drug plan if your needs change.
How does Medicare prescription drug coverage work?
Your decision about Medicare prescription drug coverage depends on the kind of healthcare
coverage you have now. There are two ways to get Medicare prescription drug coverage.
You can join a Medicare prescription drug plan or you can join a Medicare Advantage
Plan or other Medicare health plan that offers drug coverage. As a member of a
Carilion Clinic Medicare Health Plan, you are automatically enrolled in the Medicare prescription
drug plan.
Whatever plan you choose, Medicare drug coverage will help you by covering brand-name
and generic drugs at pharmacies that are convenient for you.
The health plans offered by
Carilion Clinic Medicare Health Plan
have no additional monthly premium for drug coverage and no initial deductible.
What if I have a limited income and resources or need
extra help?
There is extra help for people with limited income and resources. Almost 1 in 3
people with Medicare will qualify for extra help and Medicare will pay for almost
all of their prescription drug costs.
Carilion Clinic Medicare Health Plan
can work with you to help you apply for extra help or Member Services help you if
you believe your current extra help status is incorrect. To reach the
Carilion Clinic Medicare Health Plan
Member Services department:
Call us at 866-544-6981, TTY: 800-716-3231, 8 am to 8 pm, 7 days a week. Or see more contact options.
Get more information on who can get extra help
with prescription drug costs.
Questions About Prescription Drug Coverage with a
Carilion Clinic Medicare Health Plan
Network Pharmacies
Carilion Clinic Medicare Health Plan
has contracts with over 58,000 pharmacies that equals or exceeds CMS requirements
for pharmacy access in your area.
How do I fill a prescription at a network pharmacy?
To fill your prescription, show your plan membership card at the network pharmacy
you choose. When you show your plan membership card, the network pharmacy will automatically
bill the plan for our share of your covered prescription drug cost. You will need
to pay the pharmacy your share of the cost when you pick up your prescription. If
you don’t have your plan membership card with you when you fill your prescription,
ask the pharmacy to call the plan to get the necessary information.
If the pharmacy is not able to get the necessary information, you may have to pay
the full cost of the prescription when you pick it up. (You can then ask us to reimburse
you for our share. Information on this procedure can be found in your Evidence Of
Coverage document).
Your out-of-pocket costs are lower when you utilize network pharmacies.
In most cases, your prescriptions are covered only if they are filled at the plan’s
network pharmacies.
A network pharmacy is a pharmacy that has a contract with the plan to provide your
covered prescription drugs. The term “covered drugs” means all of the
Part D prescription drugs that are covered by the plan.
Preferred pharmacies are pharmacies in our network where the plan has negotiated
lower costsharing for members for covered drugs than at non-preferred pharmacies.
However, you will still have access to lower drug prices at non-preferred pharmacies
than at out-of-network pharmacies. You may go to either of these types of network
pharmacies to receive your covered prescription drugs.
How do I find a network pharmacy?
You can look in your Pharmacy Directory, search our online pharmacy directory, or
Call us at 866-544-6981, TTY: 800-716-3231, 8 am to 8 pm, 7 days a week. Or see more contact options.
Choose whatever is easiest for you.
You may go to any of our network pharmacies. If you switch from one network pharmacy
to another, and you need a refill of a drug you have been taking, you can ask to
either have a new prescription written by a doctor or to have your prescription
transferred to your new network pharmacy.
You can find a link to the searchable pharmacy directory by selecting a specific
health plan from Our Medicare Plans overview page.
How do I fill a prescription through mail-order?
For certain kinds of drugs, you can use the plan’s network mail-order services.
These drugs are marked as “mail-order” drugs on our plan’s Drug
List. (Mail-order drugs are drugs that you take on a regular basis, for a chronic
or long-term medical condition.)
Our plan’s mail-order service requires you to order at least a 90-day supply
of the drug and no more than a 90-day supply.
To get order forms and information about filling your prescriptions by mail. Please
call the pharmacy number listed in the Members Section on the back of your ID card.
If you use a mailorder pharmacy not in the plan’s network, your prescription
will not be covered.
Usually a mail-order pharmacy order will get to you in no more than 21 days. If
you experience a delay, please call the pharmacy number listed in the Members Section
on the back of your ID card.
Filling a prescription outside the network (out-of-network coverage):
Generally, we cover drugs filled at an out-of-network pharmacy only when you are
not able to use a network pharmacy. Here are the circumstances when we would cover
prescriptions filled at an out-of-network pharmacy:
- When you cannot obtain a covered drug in a timely manner within the service area
because there is no network pharmacy within a reasonable driving distance that provides
24/7 service
- When you must fill a prescription for a covered drug that is not regularly stocked
at an accessible network retail or mail-order pharmacy
- When you are receiving a covered drug from an out-of-network institution-based pharmacy
while a patient in an emergency department, provider-based clinic, outpatient surgery,
or other outpatient setting(s)
- When you travel outside the Part D plan’s service area and:
- Run out of or lose the covered drug(s).
- Becomes ill and needs a covered Part D drug; and cannot access a network pharmacy.
- During any State or Federal disaster declaration, or other public health emergency
declaration, in which you are evacuated or otherwise displaced from your place of
residence and cannot reasonably be expected to obtain covered drugs at a network
pharmacy.
- In circumstances in which normal distribution channels are unavailable, the plan
shall liberally apply its out-of-network policies to facilitate access to medications.
- When you receive vaccines and other covered drugs appropriately dispensed and administered
by a physician in a physician’s office.
In these situations, please check first with Member Services to see if there is
a network pharmacy nearby.
If you go to an out-of-network pharmacy and try to use your membership card to fill
a prescription, the pharmacy may not be able to submit the claim directly to us.
When that happens, you will have to pay the full cost of your prescription. Save
your receipt and send a copy to us when you ask us to pay you back for our share
of the cost.
What is the
Carilion Clinic Medicare Health Plan
formulary?
The plan has a “List of Covered Drugs", called the formulary. The drugs on
this list are selected by the plan with the help of a team of doctors and pharmacists.
The formulary must meet requirements set by Medicare. Medicare has approved the
plan’s formulary. The formulary contains the prescription drugs believed to
be a necessary part of a quality treatment program.
Carilion Clinic Medicare Health Plan
will generally cover the drugs listed in our formulary as long as the drug is medically
necessary, the prescription is filled at a
Carilion Clinic Medicare Health Plan
network pharmacy and other plan rules are followed. For more information on how
to fill your prescriptions, please review your Evidence of Coverage.
You can find a link to the searchable formulary by selecting a specific health plan
from Our Medicare Plans overview page.
Can the formulary change?
Yes. Most of the changes in drug coverage happen at the beginning of each year (January
1). However, during the year, the plan might make many kinds of changes to the Drug
List. For example, the plan might:
- Add or remove drugs from the Drug List. New drugs become available, including new
generic drugs. Perhaps the government has given approval to a new use for an existing
drug. Sometimes, a drug gets recalled and we decide not to cover it. Or we might
remove a drug from the list because it has been found to be ineffective.
- Move a drug to a higher or lower cost-sharing tier.
- Add or remove a restriction on coverage for a drug (for more information about restrictions
to coverage, see Section 5 in this chapter).
- Replace a brand-name drug with a generic drug.
In almost all cases, we must get approval from Medicare for changes we make to the
plan’s Drug List.
If there is a change to coverage for a drug you are taking, the plan will send you
a notice to tell you. Normally, we will let you know at least 60 days ahead of time.
Once in a while, a drug is suddenly recalled because it’s been found to be
unsafe or for other reasons. If this happens, the plan will immediately remove the
drug from the Drug List. We will let you know of this change right away. Your doctor
will also know about this change, and can work with you to find another drug for
your condition.
Can the list of network pharmacies change?
Yes,
Carilion Clinic Medicare Health Plan
may add or remove pharmacies from our pharmacy listing. For the most up-to-date
information about our network pharmacies in your area:
Call us at 866-544-6981, TTY: 800-716-3231, 8 am to 8 pm, 7 days a week. Or see more contact options.
Drug Utilization Management
Are there any other restrictions on coverage?
For certain prescription drugs, special rules restrict how and when the plan covers
them. A team of doctors and pharmacists developed these rules to help our members
use drugs in the most effective ways. These special rules also help control overall
drug costs, which keeps your drug coverage more affordable.
In general, our rules encourage you get a drug that works for your medical condition
and is safe. Whenever a safe, lower-cost drug will work medically just as well as
a higher-cost drug, the plan’s rules are designed to encourage you and your
doctor to use that lower-cost option. We also need to comply with Medicare’s
rules and regulations for drug coverage and cost sharing.
Our plan uses different types of restrictions to help our members use drugs in the
most effective ways. The sections below tell you more about the types of restrictions
we use for certain drugs.
- Using generic drugs whenever you can
A “generic” drug works the same as a brand-name drug, but usually costs
less. However, if your doctor has told us the medical reason that the generic drug
will not work for you, then we will cover the brand-name drug. (Your share of the
cost may be greater for the brand-name drug than for the generic drug.)
- Getting plan approval in advance
For certain drugs, you or your doctor need to get approval from the plan before
we will agree to cover the drug for you. This is called “prior authorization.”
Sometimes plan approval is required so we can be sure that your drug is covered
by Medicare rules. Sometimes the requirement for getting approval in advance helps
guide appropriate use of certain drugs. If you do not get this approval, your drug
might not be covered by the plan.
Your physician can use
this form to request a
prior authorization.
- Trying a different drug first
This requirement encourages you to try safer or more effective drugs before the
plan covers another drug. For example, if Drug A and Drug B treat the same medical
condition, the plan may require you to try Drug A first. If Drug A does not work
for you, the plan will then cover Drug B. This requirement to try a different drug
first is called “Step Therapy.”
- Quantity limits
For certain drugs, we limit the amount of the drug that you can have. For example,
the plan might limit how many refills you can get, or how much of a drug you can
get each time you fill your prescription. For example, if it is normally considered
safe to take only one pill per day for a certain drug, we may limit coverage for
your prescription to no more than one pill per day.
The plan’s formulary includes information about the restrictions described
above. To find out if any of these restrictions apply to a drug you take or want
to take, check the formulary.
What if my drug is not on the formulary?
If your drug is not on the formulary or is restricted, here are things you can do:
- You may be able to get a temporary supply of the drug (only members in certain situations
can get a temporary supply).
- You can change to another drug.
- You can request an exception and ask the plan to cover the drug in the way you would
like it to be covered.
Transition Policy
As a new or continuing member in our plan, you may be taking drugs that are not
on our formulary. Or you may be taking a drug that is on our formulary but your
ability to get it is limited. For example, you may need a prior authorization from
us before you can fill your prescription. You should talk to your doctor to decide
if you should switch to an appropriate drug that we cover or request a formulary
exception so that we will cover the drug you take. While you talk to your doctor
to determine the right course of action for you, we may cover your drug in certain
cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your
drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription
written for fewer days) when you go to a network pharmacy. After your first 30-day
supply, we will not pay for these drugs, even if you have been a member of the plan
less than 90 days.
If you are a resident of a long-term care facility, we will cover a temporary 34-day
transition supply (unless you have a prescription written for fewer days). We will
cover more than one refill of these drugs for the first 90 days you are a member
of our plan. If you need a drug that is not on our formulary or if your ability
to get your drugs is limited, but you are past the first 90 days of membership in
our plan, we will cover a 34-day emergency supply of that drug (unless you have
a prescription for fewer days) while you pursue a formulary exception.
Other times when we will cover a temporary 34-day transition supply (or less, if
you have a prescription written for fewer days) include:
- When you enter a long-term care facility
- When you leave a long-term care facility
- When you are discharged from a hospital
- When you leave a skilled nursing facility
- When you cancel hospice care
Carilion Clinic Medicare Health Plan will send you a letter within 3 business days
of your filling a temporary transition supply notifying you that this was a temporary
supply and explaining your options.
How do I request an exception to the
Carilion Clinic Medicare Health Plan
formulary?
When you ask for an exception, your doctor or other prescriber will need to explain
the medical reasons why you need the exception approved. We will then consider your
request. Here are three examples of exceptions that you or your doctor or other
prescriber can ask us to make:
-
Covering a Part D drug for you that is not on our plan’s List of Covered Drugs
(Formulary).
- If we agree to make an exception and cover a drug that is not on the Drug List,
you will need to pay the cost-sharing amount that applies to all of our drugs. You
cannot ask for an exception to the copayment or co-insurance amount we require you
to pay for the drug.
- You cannot ask for coverage of any “excluded drugs” or other non-Part
D drugs which Medicare does not cover.
-
Removing a restriction on the plan’s coverage for a covered drug.There are
extra rules or restrictions that apply to certain drugs on the plan’s List
of Covered Drugs.
-
Changing coverage of a drug to a lower cost-sharing tier. Every drug on the plan’s
Drug List is in one of four cost-sharing tiers. In general, the lower the cost-sharing
tier number, the less you will pay as your share of the cost of the drug.
- If your drug is in the non-preferred tier you can ask us to cover it at the cost-sharing
amount that applies to drugs in the preferred tier. This would lower your share
of the cost for the drug.
- You cannot ask us to change the cost-sharing for any drug in tier four for specialty
or non-formulary drugs.
Medical Management
Medical Management is an important component of promoting high-quality, cost-effective
healthcare. Medical Management is not the practice of medicine. Your health plan
physician practices medicine and manages your care. Medical management is a process
that oversees the services provided to members to ensure they are provided in the
highest quality, most cost-effective manner.
Quality Improvement Program
Carilion Clinic Medicare Health Plan
is always working to improve the quality of healthcare and customer service we offer
our members. By following strict standards of care and monitoring the delivery of
that care, we are able to measure our success. Our Quality Improvement team plans
and implements programs to improve the delivery of care and ensure positive health
outcomes for members.
Medication Therapy Management
Medication Therapy Management (MTM) is a program offered to members of our Medicare
Part D prescription drug plans. MTM is an opt-out program that is offered to our
members, with limited eligibility requirements, to assist with controlling chronic
disease. The MTM program is not actually a plan benefit, it is an educational program
offered to members.
For additional information about the program and eligibility, members should
contact us.
Affirmative Statement About Incentives
Medical management is the process that promotes high quality healthcare in a cost-effective
manner.
It is the policy of
Carilion Clinic Medicare Health Plan
that financial incentives are not used to encourage barriers to care or service. Carilion Clinic Medicare Health Plan does
not encourage decisions that may result in under- or over-utilization in medical
or behavioral health services.
Decision-making in the medical management process is based only on the appropriateness
of care, service and existing coverage.
Carilion Clinic Medicare Health Plan
does not reward its physicians, nurses or pharmacists who perform utilization review
for issuing denials in the provision of care or service.
To ensure that appropriate decision making occurs in the medical management arena,
Carilion Clinic Medicare Health Plan
monitors data and information for under- and over-utilization.
Grievance, Exceptions, Coverage Determinations and Appeals Procedures
What is a coverage determination?
As a member of Carilion Clinic Medicare Health Plan (Bronze, Silver, Gold, Platinum),
you have the right to request a coverage determination, which includes the right
to request an exception, the right to file an appeal if we deny coverage for a prescription
drug, and the right to file a grievance. You have the right to request a coverage
determination if you want us to cover a Part D drug that you believe should be covered.
An exception is a type of coverage determination. You may ask us for an exception
if you believe you need a drug that is not on our list of covered drugs or believe
you should get a non-preferred drug at a lower out-of-pocket cost. You can also
ask us for an exception to cost utilization rules, such as a limit on the quantity
of a drug. If you think you need an exception, you should contact us before you
try to fill your prescription at a pharmacy. Your doctor must provide a statement
to support your exception request. If we deny coverage for your prescription drug(s),
you have the right to appeal and ask us to review our decision. Finally, you have
the right to file a grievance if you have any type of problem with us or one of
our network pharmacies that does not involve coverage for prescription drug.
You can ask us for a coverage determination yourself or your prescribing physician
or someone you name may do it for you. Download our
Coverage
Determination form, and follow the directions on the form.
If someone submits a form on your behalf, this person would be your "Appointed Representative".
You can name a relative, friend, advocate, doctor or anyone else to act for you.
Download our
Request
for Appointment of Representative form, and follow the directions on the
form.
The Evidence of Coverage provides more details on coverage determinations.
Contact Information
What are appeals and grievances?
Your health and satisfaction are important to us. When you have a problem or concern,
we hope you'll try an informal approach first by contacting Carilion Clinic Medicare
Health Plan. We will work with you to try to find a satisfactory solution to your
problem.
You have rights as a member of our plan and as someone who is getting Medicare.
We pledge to honor your rights, to take your problems and concerns seriously, and
to treat you with respect.
Sometimes you might need a formal process for dealing with a problem you are having
as a member of our plan.
- For some types of problems, you need to use the process for coverage decisions and
making appeals. ("Appeals")
- For other types of problems you need to use the
process for making complaints. ("Grievances")
Both of these processes have been approved by Medicare. To ensure fairness and prompt
handling of your problems, each process has a set of rules, procedures, and deadlines
that must be followed by us and by you.
Appeals
An appeal is a type of complaint you make when you want a reconsideration of a decision
(determination) that was made regarding a service, or the amount of payment your
Medicare Advantage Health Plan pays or will pay for a service or the amount you
must pay for a service.
You can request an appeal yourself or ask someone to act on your behalf. If you
ask someone to file an appeal for you, he or she will need to submit your written
permission with the appeal.
An authorized legal representative, such as a court-appointed guardian, may also
submit an appeal.
In the case where your health may be in danger, your provider can file an expedited
appeal on your behalf.
You may file an appeal within sixty (60) calendar days of the date of the notice
of the initial organization determination. For example, you may file an appeal for
any of the following reasons:
- Your Medicare Advantage health plan refuses to cover or pay for services you think
your Medicare Advantage health plan should cover.
- Your Medicare Advantage health plan or one of the Contracting Medical Providers
refuses to give you a service you think should be covered.
- Your Medicare Advantage health plan or one of the Contracting Medical Providers
reduces or cuts back on services you have been receiving.
- If you think that your Medicare Advantage health plan is stopping your coverage
too soon.
Note: The sixty (60) day limit may be extended for good cause. Include in your written
request the reason why you could not file within the sixty (60) day timeframe.
There are two kinds of appeals: standard and expedited (fast).
A standard appeal request must be in writing however an expedited appeal can be
submitted in writing or verbally by telephone. Please use the appropriate address
or telephone number below. For additional information about appeals, please refer
to your Evidence of Coverage.
- Medical Appeals:
Carilion Clinic Medicare Health Plan
Medical Management
10008 N. Dale Mabry Hwy
Tampa, FL 33618
Phone: 1-866-777-5993
Fax: 800-323-0419
(Monday through Friday, 8 AM to 5 PM)
- Part D Prescription Drug Appeals:
Carilion Clinic Medicare Health Plan
Medicare Appeals
P. O. Box 630367
Irving, TX 75063-0118
Phone: 1-866-544-6981
Fax: 888-235-8551
(Monday through Friday, 8 AM to 5 PM)
You should include: your name, address, telephone number, member ID number, reasons
for appealing, and any evidence you wish to attach. You may send in supporting medical
records, doctors' letters, or other information that explains why your plan should
provide the service. Call your doctor if you need this information to help you with
your appeal.
If you appeal, we will review the decision. If any of the services you requested
are still denied after our review, Medicare will provide you with a new and impartial
review of your case by a reviewer outside of our Medicare Advantage Prescription
Drug Plan. If you disagree with that decision, you will have further appeal rights.
You will be notified of those appeal rights if this happens.
Standard Appeals: Standard appeals are processed within 30 calendar days from the
date we receive your request, but may be extended to 44 calendar days if additional
information is needed. You will receive notice of our decision in writing along
with any supporting explanation.
Standard appeals for Part D prescription drug coverage determination appeals are
made within 72 hours of receipt.
Fast Decisions/Expedited Appeals: You have the right to request and receive expedited
decisions affecting your medical treatment in "Time-Sensitive" situations. A Time-Sensitive
situation is a situation where waiting for a decision to be made within the timeframe
of the standard decision-making process could seriously jeopardize:
- your life or health.
- your ability to regain maximum function.
If your Medicare Advantage health plan or your Primary Care Physician decides, based
on medical criteria that your situation is Time-Sensitive or if any physician calls
or writes in support of your request for an expedited review, your Medicare Advantage
Health Plan will issue a decision as expeditiously as possible, but no later than
seventy-two (72) hours after receiving the request.
Expedited Part D prescription drug coverage determination appeals are made within
24 hours.
Grievances
A grievance is a type of complaint you make if you have a complaint or problem that
does not involve payment or services by your Medicare Advantage Health Plan or a
Contracting Medical Provider.
For example, you would file a grievance if:
- you have a problem with things such as the quality of your care during a hospital
stay
- you feel you are being encouraged to leave your plan
- waiting times on the phone, at a network pharmacy, in the waiting room, or in the
exam room
- waiting too long for prescriptions to be filled
- the way your doctors, network pharmacists or others behave
- not being able
to reach someone by phone or obtain the information you need
- or lack of cleanliness or the condition of the doctor's office
You can submit a grievance yourself, or designate a representative to submit the
grievance for you. Your provider, however, may not file a grievance on your behalf.
You may file a grievance within sixty (60) calendar days of the date of the circumstance
giving rise to the grievance. There is no filing limit for complaints concerning
quality of care. Note: The sixty (60) day limit may be extended for good cause.
Include in your written request the reason why you could not file within the sixty
(60) day timeframe.
You have the right to request a fast review or expedited grievance if you disagree
with your Medicare Advantage Health Plan's decision to invoke an extension on your
request for an organization determination or reconsideration, or your Medicare Advantage
Health Plan's decision to process your expedited request as a standard request.
In such cases, your Medicare Advantage Health Plan will acknowledge your grievance
within twenty-four (24) hours of receipt and notify you in writing of your Medicare
Advantage Health Plan's conclusion within three (3) calendar days.
A grievance may be filed by contacting us by telephone or writing directly to us
using the addresses and telephone numbers listed below. For additional information
about grievances, please refer to your Evidence of Coverage, specifically the following
sections:
Section 1 – Introduction
Section 2 - You can get help from government organizations that
are not connected with us
Section 3 - To deal with your problem, which process should you
use?
Section 4 - A guide to the basics of coverage decisions and appeals
Section 5 - Your medical care: How to ask for a coverage decision
or make an appeal
Section 6 - Your Part D prescription drugs: How to ask for a coverage
decision or make an appeal
Section 7 - How to ask us to cover a longer hospital stay if you
think the doctor is discharging you too soon
Section 8 - How to ask us to keep covering certain medical services
if you think your coverage is ending too soon
Section 9 - Taking your appeal to Level 3 and beyond
Section 10 - How to make a complaint about quality of care, waiting
times, customer service, or other concerns
Plan EOC Documents
Bronze (HMO-POS) Evidence of
Coverage with Annual Notice of Changes
Silver (HMO-POS) Evidence
of Coverage with Annual Notice of Changes
Gold (HMO-POS) Evidence of
Coverage with Annual Notice of Changes
Platinum (HMO-POS) Evidence
of Coverage
Contact Information
- Standard Medical Grievances:
Carilion Clinic Medicare Health Plan
Grievance Coordinator
P.O. Box 3389
Scranton, PA 18505
Bronze: 1-877-233-7055
Silver: 1-877-233-7056
Gold: 1-877-233-7057
(Monday through Friday, 8 AM to 5 PM)
- Part D Prescription Drugs Expedited Grievances:
Carilion Clinic Medicare Health Plan
Medicare Grievances
P. O. Box 630367
Irving, TX 75063-0118
1-866-544-6981
(Monday through Friday, 8 AM to 5 PM)
- Expedited Medical Grievances:
Carilion Clinic Medicare Health Plan
Medicare Grievances
10008 N. Dale Mabry Hwy
Tampa, FL 33618
1-800-680-1246
(Monday through Friday, 8 AM to 5 PM)
Standard grievance requests are usually decided upon within 30 calendar days from
the date we receive your request, but may be extended if additional information
is needed. You will receive notice of our decision in writing along with any supporting
explanation.
Standard appeals for Part D prescription drug coverage determination appeals are
made within 72 hours of receipt.
Decisions on expedited grievance requests are made within 72 hours (3 calendar days)
of the receipt of the request. If we determine that the grievance request should
be standard instead, we will promptly notify you with that decision and follow up
with a written notice within 2 calendar days.
Expedited Part D prescription drug grievance requests are made within 24 hours.
If you would like to obtain an aggregate number of grievances, appeals, and exceptions
filed with the plan sponsor, please call 1-877-335-0202 (Monday through Friday,
8 AM to 5 PM).
Other Important Information
Potential for Contract Termination
The health plans of Carilion Clinic Medicare Health Plan have contracts with the
Centers for Medicare and Medicaid Services (CMS), the government agency that runs
Medicare. This contract renews each year. At the end of each year, the contract
is reviewed and either Carilion Clinic Medicare Health Plan or CMS can decide to
end it. You will get 90-days advance notice in this situation. It is possible for
our contract to end at some other time during the year, too. In these situations
we will try to tell you 90 days in advance, but your advance notice may be as little
as 30 or fewer days if CMS must end our contract in the middle of the year.
Whenever a Medicare health plan leaves the Medicare program or stops serving your
area, you will be provided a special enrollment period to make choices about how
you get Medicare, including choosing a Medicare Prescription Drug Plan and guaranteed
issue rights to a Medigap policy.
Disenrollment
If you want to leave your MA plan and don't want to join another MA plan, you must
send a written request to the plan or call 1-800-MEDICARE during the enrollment
periods outlined above. Your disenrollment will generally be effective the first
day of the month following the month of your disenrollment request. Medicare will
not pay if you use providers and services outside the MA plan's network before the
effective date of your disenrollment.
If you want to switch from one MA plan to another, simply submit an enrollment application
to the new plan and once you are accepted, you will be automatically disenrolled
from your current plan. In general, you can only make changes such as this during
the AEP and OEP.
Note: This method of disenrollment also applies to Part D prescription
drug coverage. For example, if you are in an MA plan with Part D coverage (MA-PD)
and wish to switch to a stand-alone prescription drug plan (PDP), enrolling in a
PDP automatically disenrolls you from your previous MA-PD plan, and vice versa.
For more information
For more detailed information about your
Carilion Clinic Medicare Health Plan
prescription drug coverage, please review your Evidence of Coverage and other plan
materials. These documents can be found by selecting your plan from the
Plans Overview page, and navigating to the [Docments and Forms] section.
If you have questions about
Carilion Clinic Medicare Health Plan
Pharmacy (PART D):
Call us at 866-544-6981, TTY: 800-716-3231, 8 am to 8 pm, 7 days a week. Or see more contact options.
If you have general questions about Medicare prescription drug coverage, please
call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD
users should call 1-877-486-2048. Or, visit
medicare.gov.
Documents and Forms
Pharmacy Prior Authorization/Non-Formulary
Request
Request
for Appointment of Representative
Request for Appointment of Representative (CMS Site)
Request for an
Appeal, Grievance, or Redetermination
Medicare
Prescription Drug Determination Request form (for use by enrollees)
Medicare Prescription Drug Determination Request form (for use by enrollees) (CMS Site)
Medicare Prescription Drug Determination
Request form (for use by Providers)
[
] Adobe Reader required
Viewing these documents requires the Adobe Acrobat Reader, which can be downloaded
for free by
clicking here.
