To have several grievances, appeals, or exceptions filed with our Plan, contact Blue Cross Medicare Advantage Customer Service at 1-877-774-8592 (TTY 711). Appointment of Representative You may choose someone to act on your behalf. You may choose a relative, friend, sponsor, lawyer or a doctor. A court may also appoint someone.
What is the Blue Cross and blue shield of Illinois prescription drug list?
Call Blue Cross Medicare Advantage Customer Service at 1-877-774-8592 (TTY 711 ). There are several types of coverage determinations. Prior Authorization To ask us for a pharmacy prior authorization, step therapy exception or quantity limit exception, you or someone on your behalf must fill out and fax the form below to 1-800-693-6703.
How do I get a pharmacy prior authorization from Blue Cross?
When you request a formulary, tier, or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement.
What is a formulary exception form?
Find Medicare Advantage, prescription drug, Medicare Supplement, and other forms to help you manage your Medicare plan. Forms & Documents | Blue Cross and Blue Shield of Illinois This page may have documents that can’t be read by screen reader software.
How do I appeal a Blue Cross prescription drug decision?
The Blue Cross and Blue Shield of Illinois (BCBSIL) Prescription Drug List (also known as a Formulary) is designed to serve as a reference guide to pharmaceutical products. However, the drug list is not intended to be a substitute for a doctor's clinical knowledge and judgment. In all cases, a doctor is expected to select the most appropriate ...
What is a formulary exception request?
request letter. A formulary exception is a type of coverage determination used when a drug is not included on a health plan's formulary or is subject to a National Drug Code (NDC) block.
How do I file an appeal with Blue Cross Blue Shield of Illinois?
There are two ways to file an appeal or grievance (complaint): Call Member Services at 1-877-860-2837. If you do not speak English, we can provide an interpreter at no cost to you. If you are hearing impaired, call the Illinois Relay at 711.
What is a coverage exception?
Coverage Exception Criteria These criteria apply to any request for medication that is not included on the covered drug list (formulary) and can be used to treat a medical condition/disease state that is not otherwise excluded from coverage under the pharmacy benefit.
What is a formulary for Medicare?
A Medicare formulary is a list of prescription drugs that are covered by a Medicare Part D plan. Coverage for a specific drug may vary from plan to plan. Each Medicare Part D plan has its own unique formulary, meaning that it has its own unique list of drugs the plan covers.Jun 5, 2021
What is the difference between a claim and an appeal?
You file a claim when you submit it to the VA. To receive disability compensation, you will need to prove that your current disability is connected to your military service. An appeal occurs after you receive a decision from the VA on your claim.Jun 12, 2017
How do you start availity of appeal?
Click on Login and enter your Availity ID and password. Select Claims from the left-hand navigation menu. Select Appeal Claim from the left-hand navigation menu, and then Go to Availity.
How does a formulary exception work?
A formulary exception is a type of coverage determination request whereby a Medicare plan member asks the plan to cover a non-formulary drug or amend the plan's usage management restrictions that are placed on the drug (for example if the plan has a 30 pill per 30 day Quantity Limit, you might ask for a formulary ...
What does not on formulary mean?
If a medication is “non-formulary,” it means it is not included on the insurance company's “formulary” or list of covered medications. A medication may not be on the formulary because an alternative is proven to be just as effective and safe but less costly.Mar 7, 2021
What is a Medicare tier exception?
A tiering exception is a type of coverage determination used when a medication is on a plan's formulary but is placed in a nonpreferred tier that has a higher co-pay or co-insurance. Plans may make a tier exception when the drug is demonstrated to be medically necessary.
How is formulary defined?
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.
What are formulary guidelines?
A formulary system is the ongoing process through which a healthcare organization establishes policies regarding the use of drugs, therapies, and drug-related prod- ucts, including medication delivery devices, and identifies those that are most medically appropriate, safe, and cost-effective to best serve the health ...
What is formulary administration?
Formulary Management. Formulary management is an integrated patient care process which enables physicians, pharmacists and other health care professionals to work together to promote clinically sound, cost-effective medication therapy and positive therapeutic outcomes.
What is a formulary exception?
The formulary exception process is used to ask for coverage for a medication that’s not on the plan formulary. All approvals for non-formulary medications require a Tier 4 copay for brand name and generic drugs.
What is a grievance in Medicare?
A grievance is a complaint about quality of care or other services you get from a Medicare provider. It’s not about failure to cover or pay for a certain drug. Use the determination process covered above for those concerns.
What is formulary exception?
The Formulary Exception process allows members to apply for coverage of a non-covered drug if they have tried and failed the covered drug (s). Select the list of exceptions for your plan.
What is the new to market drug review exception?
The New to Market FDA-Approved Medication Review Exception Process allows a member to apply for coverage of an excluded drug at a tier 3 cost share if the member has met the requirements outlined.
What is SF 2809?
Health Benefits Election Form (SF 2809 Form) To enroll, reenroll, or to elect not to enroll in the FEHB Program, or to change, cancel or suspend your FEHB enrollment please complete and file this form. English.
What is a formulary exception?
A formulary exception should be requested to obtain a Part D drug that is not included on a plan sponsor's formulary, or to request to have a utilization management requirement waived ( e.g., step therapy, prior authorization, quantity limit) for a formulary drug.
How long does it take to get an exception request from a plan sponsor?
For requests for benefits, once a plan sponsor receives a prescriber's supporting statement, it must provide written notice of its decision within 24 hours for expedited requests or 72 hours for standard requests. The initial notice may be provided verbally so long as a written follow-up notice is ...
What is tiering exception?
Exceptions. An exception request is a type of coverage determination. An enrollee, an enrollee's prescriber, or an enrollee's representative may request a tiering exception or a formulary exception. A tiering exception should be requested to obtain a non-preferred drug at the lower cost-sharing terms applicable to drugs in a preferred tier.
When are exceptions granted?
Exceptions requests are granted when a plan sponsor determines that a requested drug is medically necessary for an enrollee. Therefore, an enrollee's prescriber must submit a supporting statement to the plan sponsor supporting the request.
Can a prescriber submit a supporting statement?
A prescriber may submit his or her supporting statement to the plan sponsor verbally or in writing. If submitted verbally, the plan sponsor may require the prescriber to follow-up in writing. A prescriber may submit a written supporting statement on the Model Coverage Determination Request Form found in the " Downloads " section below, ...
What are the tiers of a drug?
Tiers are the different cost levels you pay for a drug. For Standard Option and Basic Option you will generally pay the lowest cost share for any Tier 1 generic drug or Tier 4 Preferred specialty drug. If your drug is in Tiers 2, 3 or 5, look to see if there is a generic or Preferred drug option available, and discuss these options with your doctor. For FEP Blue Focus you will generally pay the lowest cost share for any Tier 1 generic drug. If your drug is in Tier 2 or non-covered, look to see if there is a generic or Preferred drug option available, and discuss these options with your doctor.
What is preferred specialty drug?
Preferred Specialty Drugs. Proven to be safe, effective, and favorably priced compared to Non-pre ferred specialty drugs. Non-preferred Specialty Drugs. These drugs typically have a Preferred brand available, therefore your cost share will be higher.
Is Blue Focus covered by FEP?
Non-covered Drugs. FEP Blue Focus has a closed formulary. This means that only drugs listed on the formulary are covered. Click here for the FEP Blue Focus full formulary. FEP Blue Focus members taking a non-covered drug should expect to pay the full cost of the prescription.
Does mail service fill prescriptions?
Mail Service and Specialty Programs will not fill prescriptions that need prior approval until we approve your prior approval request. Preferred retail pharmacies will fill your prescriptions, but you will pay the full cost of the drug until we approve your prior request.
Is generic drug covered by standard option?
A few drugs are no longer covered on the Standard Option formulary. These exclu ded drugs have other drugs available that treat the same condition - either generic drugs, brand name drugs or both. These options are effective and safe, and they may help you save money on your prescriptions.
Appeals and Grievances
- If you have issues, complaints or problems with your Medicare plan or the care you receive, you have the right to make a complaint. 1. Determination:A request to make an exception to the plan services or benefits or the amount the plan will pay for a service or benefit. 2. Appeal:A request to reconsider and change a decision or determination made a...
Prescription Drug Coverage Determinations, Redeterminations and Appeals
- If your doctor or pharmacist tells you that a prescription drug is not covered, you may ask the plan for an exception, a coverage determination, redetermination or an appeal. You can also ask for help to find a different drug. Here are examples of when you may want to ask the plan for an exception, a coverage determination and an appeal: 1. If there is a required limit on the quantity (…
Step 1: Initial Coverage Determination Request
- Questions? Call Blue Cross MedicareRx Customer Service at 1-888-285-2249 TTY 711. There are several types of coverage determination.