Exception and Appeal Rights for Prescription Drugs
If there is a medical necessity for the use of a particular non-formulary drug, you can ask us to make an exception and cover your drug. There are several types of exceptions that you can ask us to make:
We will respond to your request within 72 hours.
If your exception request is denied, you will receive a letter telling you why the request has been denied. This letter also describes your right to appeal the decision.
There Are Two Kinds of Appeals You Can Request
If you request a standard appeal, we must give you a decision no later than 7 days after we get your appeal.
You can request an expedited (fast) appeal if you or your doctor believe that your health could be seriously harmed by waiting up to 7 days for a decision. If your request to expedite is granted, we must give you a decision no later than 72 hours after we receive your appeal.
If the doctor who prescribed the drug(s) requests an expedited appeal for you, or supports your request for a faster appeal process, we will automatically grant you a faster decision. If you request a fast appeal without support from a doctor, we will decide whether or not your health situation requires a fast appeal. If we determine that your health does not require a fast decision, we will reach a decision within 7 days.
Note: Your appeal will not be expedited if you’ve already received the drug you are appealing.
What Do I Include with My Appeal Request?
You should include the following:
If your appeal relates to a decision made by us to deny a drug that is not on our formulary, your prescribing physician must indicate that none of the drugs on any tier of our formulary would be as effective to treat your condition as the requested off-formulary drug.
How Do I Request an Appeal?
For an Expedited Appeal: You or your appointed representative should contact us by telephone or fax at the numbers to the right.
For a Standard Appeal: You or your appointed representative should mail or deliver your written appeal request to the address(es) below:
Medicare Advantage Plans
True Blue HMO
P.O. Box 8406, Boise, ID 83707
What Happens Next?
If you appeal, we will review your case and give you a decision. If any of the prescription drugs you requested are still denied, you can request an independent review of your case by a reviewer outside of your Medicare Drug Plan.
If you disagree with that decision, you will have the right to further appeal. You will be notified of your appeal rights if this happens.
If you need help with an appeal, call Customer Service at 1-888-494-2583 or TTY/TDD 1-800-377-1363, 8:00 a.m. to 8:00 p.m. (MT), seven days a week.
Other Resources To Help You:
Y0010_MK 13121 Approved 12-31-2012
Last updated 11-14-2012