name> be covered even though it is not on your plans formulary. They must give a supporting statement that explains that all other drugs on the formulary would have adverse effects (be harmful to you) or be less effective (not work as well). You can also make this request to us. We will then reach out to your doctor to see if they feel this is the only drug that will work for you. Drug Tier Questions Every drug on the plan’s Drug List is in one of five (5) cost-sharing tiers. In general, the higher the cost-sharing tier, the higher your cost for the drug: Tier 1: (Preferred Generic Drugs) Tier 1 is your lowest-cost Generic tier and includes preferred generic drugs. Generic drugs contain the same active ingredients as brand drugs and are equally safe and effective. Tier 2: (Generic Drugs)This is your higher-cost Generic tier and includes generic drugs and sometimes some preferred brand drugs. Tier 3: (Preferred Brand Drugs) This is your middle-cost tier, and includes preferred brand Plan Benefits Remember to include the Extra Help paragraph. Warning: Remember to check if the member is asking for a coverage determination for the brand drug.
the pharmacy is delivering the correct drug (including strength, amount, and form) and, if necessary, allow you to cancel or delay the order before you are billed and it is shipped. It is important that you respond each time you are contacted by the pharmacy, to let them know what to do with the new prescription and to prevent any delays in shipping. To opt out of automatic deliveries of new prescriptions received directly from your health care provider’s office, please contact us by calling <PBM Name > Mail Order (General) For certain kinds of drugs, you can use the plan’s network mail-order program. In most cases, the drugs provided through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. The drugs that are not available through the plan’s mail-order service are marked with a <"NM"> in our Drug List (Formulary). There are reasons that we can’t send them through mail order, like state or federal laws. Our plan’s mail-order service allows you to order up Plan Benefits (Complaining about the benefit) or Customer Service (Complaining about the program) Warning: If member is running low or out of medication, ensure to address and recommend visiting a retail pharmacy to get medication
contact member services. about benefits it may cross over into a request for benefits requiring you to forward for a decision to be made. See Dual Issue ( UM Request/OD) and Dual Issue (Pharmacy Request/CD) If a decision has already been made and they don't want to pay their cost share or feel it is wrong or denied incorrectly, this must also be opened as an appeal. Not Enough Providers (Proved False) The Member Complains there are not enough providers but we find there are. There are no network gaps. <Health Plan Name> works to give you a network of providers that meets all of our member’s needs. We are sorry that you feel that our network does not have enough providers. Thank you for telling us about this. We sent your complaint to our Provider Relations Specialist, who works to manage our provider network. We always want to make sure our members Access Use when the member feels there are not enough Providers including when there is also a quality of service where they are complaining they are restricted to a provider they don't like. You must give a listing of 3
get the proper care from providers you can choose from, so we sent your complaint to be tracked and our network reviewed. <Health Plan Name> always works to expand our Provider network with good providers. We think it’s always a good idea to keep up to date with our provider directory online at <insert web address> or give us a call. We are always here to help you in finding a Provider that can help. To make it easier on you, we have included a list of Providers located near you with this letter. We found that <Provider> is located at <address> which is about <number of miles> miles from you. <If you need a ride to your appointment <Health Plan Name> does offer <number of trips> one-way trips to Plan-approved locations every calendar year. We know it’s important for you to see your doctor so we offer this benefit even though Original Medicare doesn't. Plan-approved locations include alternate Providers with the same specialty in their area. Must report to Provider Relations/Network. You do not need to wait on a response from PR. Include transportation paragraph only if the member has transportation benefits. .
from your Social Security or Railroad Retirement Board (RRB) check, you can pay us each month by check or you can pay each month by money order. If you pay each month by check or money order, we will send you a statement. To change your payment method, please contact Member Services at the number below or on the back of your insurance card. If you are new to the plan, your payment choice can be indicated on your enrollment form, or you can also contact Member Services. If you decide to change the way you pay your premium, it can take up to three months for your new payment method to take effect. While we are processing your request for a new payment method, you are responsible for making sure that your plan premium is paid on time. If your plan has a termination clause for non-payment, educate the member.