Prescription Drug Appeals & Grievances Policy

Introduction

We encourage you to let us know right away if you have questions, concerns, or problems related to your covered services or the care you receive. Federal law guarantees your right to complain if you have concerns or problems with any part of your medical care as a plan member. The Medicare program has helped set the rules about what you need to do to make a complaint, and what we are required to do when we receive a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from Passport Advantage or penalized in any way if you make a complaint.

What are appeals and grievances?

You have the right to make a complaint if you have concerns or problems related to your coverage or care. "Appeals" and "grievances" are the two different types of complaints you can make.

An "appeal" is the type of complaint you make when you want us to reconsider and change a decision we have made about what services or benefits are covered for you or what we will pay for a service or benefit. For example, if we refuse to cover or pay for services you think we should cover, you can file an appeal. If Passport Advantage or one of our plan providers refuses to give you a service you think should be covered, you can file an appeal. If Passport Advantage or one of our plan providers reduces or cuts back on services or benefits you have been receiving, you can file an appeal. If you think we are stopping your coverage of a service or benefit too soon, you can file an appeal.

A "grievance" is the type of complaint you make if you have any other type of problem with Passport Advantage or one of our plan providers. For example, you would file a grievance if you have a problem with things such as the quality of your care, waiting times for appointments or in the waiting room, the way your providers or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of the provider's office.

Appeals: Asking Passport Advantage to change a decision about drugs we will cover or pay for

This part explains what you can do if you have problems getting the prescription drugs you believe we should provide. We use the word "provide" in a general way to include such things as authorizing prescription drugs, paying for prescription drugs, or continuing to provide a Part D prescription drug that you have been getting. Problems getting a Part D prescription drug that you believe we should provide include the following situations:

• If you are not getting a prescription drug that you believe may be covered by Passport Advantage.
• If you have received a Part D prescription drug you believe may be covered by Passport Advantage while you were a member, but we have refused to pay for the drug.
• If we will not provide or pay for a Part D prescription drug that your provider has prescribed for you because it is not on our formulary.
• If you disagree with the amount that we require you to pay for a Part D prescription drug that your provider has prescribed for you.
• If you are being told that coverage for a Part D prescription drug that you have been getting will be reduced or stopped.
• If there is a requirement that you try another drug before we pay for the drug your provider prescribed, or if there is a limit on the quantity (or dose) of the drug and you disagree with the requirement or dosage limitation.

If you are having a problem getting a Part D benefit or payment for a Part D prescription drug that you have already received, there are six steps you can take to ask for the benefit or payment you want from us. At each step, your request is considered and a decision is made. If you are unhappy with the decision, you may be able to take another step if you want to continue requesting the benefit or payment.

In Steps 1 and 2, you make your request directly to us. We review it and give you our decision.

In Steps 3 through 6, people in organizations that are not connected to us make the decisions about your request. To keep the review independent and impartial, those who review the request and make the decision in Steps 3 through 6 are part of (or in some way connected to) the Medicare program or the federal court system.

Step 1: The initial decision by Passport Advantage

The starting point is when we make an "initial decision" (also called a "coverage determination") about your Part D prescription drug or about paying for Part D drug that you have already received. When we make an "initial decision," we are giving our interpretation of how the benefits that are covered for members of Passport Advantage apply to your specific situation. You can ask for a "fast initial decision" if you have a request for benefits that needs to be decided more quickly than the standard time frame.

Step 2: Appealing the initial decision by Passport Advantage

If you disagree with the decision we make in Step 1, you may ask us to reconsider our decision. This is called an "appeal" or a "request for redetermination." You can ask for a "fast appeal" if your request for benefits needs to be decided more quickly than the standard time frame. After reviewing your appeal, we will decide whether to stay with our original decision, or change this decision and give you the benefit or payment you want.

Step 3: Review of your request by an Independent Review Organization

If we turn down your request in Step 2, you may ask an independent review organization to review our decision. The independent review organization has a contract with the federal government and is not part of Passport Advantage. The independent review organization will review your request and make a decision about whether we must give you the benefit or payment you want.

Step 4: Review by an Administrative Law Judge

If you are unhappy with the decision made by the independent review organization that reviews your case in Step 3, you may ask for an Administrative Law Judge to consider your case and make a decision. The Administrative Law Judge works for the federal government. The dollar value of your contested benefit must be at least $110 to be considered in Step 4.

Step 5: Review by a Medicare Appeals Council

If you are unhappy with the decision made in Step 4, you may be able to ask the Medicare Appeals Council (MAC) to review your case. The MAC is part of the federal department that runs the Medicare program.

Step 6: Federal Court

If you are unhappy with the decision made by the MAC in Step 5, you may be able to take your case to a Federal Court. The dollar value of your contested benefit must be at least $1090 to go to a Federal Court.

Grievances: Asking Passport Advantage to solve any other type of problem you have with the plan or one of our providers

Here are some examples of problems that are included in this category of "all other types of problems":

• Problems with the quality of the medical care you receive, including quality of care during a hospital stay.
• If you feel that you are being encouraged to leave (disenroll from) Passport Advantage.
• Problems with the customer service you receive.
• Problems with how long you have to spend waiting on the phone, in the waiting room, or in the exam room.
• Problems with getting appointments when you need them, or having to wait a long time for an appointment.
• Disrespectful or rude behavior by doctors, nurses, receptionists, or other staff.
• Cleanliness or condition of provider's offices, clinics, or hospitals.

If you have one of these types of problems and want to make a complaint, it is called "filing a grievance." In addition, you have the right to ask for a "fast grievance" if you disagree with our decision to not give you a "fast appeal" or if we take an extension on our initial decision or appeal.

If you have a complaint, we encourage you to first call Member Services. We will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.