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Your health plan must follow strict rules for how we identify, track, resolve and report all appeals and grievances. The following information applies to benefits provided by your Medicare benefit.
For information regarding your Medicaid benefit and the appeals and grievances process, please access your Medicaid Plan’s Member Handbook.
Your health plan must follow strict rules for how we identify, track, resolve and report all appeals and grievances. The following information applies to benefits provided by your Medicare benefit.
For information regarding your Medicaid benefit and the appeals and grievances process, please access your Medicaid Plan’s Member Handbook.
Who can file an Appeal?
An appeal may be filed by any of the following:
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 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:
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.
Where can an Appeal be filed?
An appeal may be filed in writing directly to us.
UnitedHealthcare Appeals and Grievances Department Part C
P. O. Box 31364
Salt Lake City, UT 84131-0364
Fax: Fax/Expedited appeals only – 1-844-226-0356
OR
Call 1-877-614-0623 TTY 711
8 a.m. - 5 p.m. PT, Monday – Friday
UnitedHealthcare Appeals and Grievances Department Part D
Attn: Medicare Part D Appeals & Grievance Dept.
You may fax your written request toll-free to 1-877-960-8235.
Or Call 1-877-614-0623 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
Why file an Appeal?
You may use the appeal procedure when you want a reconsideration of a decision (organization determination) that was made regarding a service or the amount of payment your health plan paid for a service.
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:
If your health plan or your Primary Care Provider 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 plus 14 calendar days, if an extension is taken, after receiving the request.
Grievances
Who can file a Grievance?
A grievance may be filed by any of the following:
What is a Grievance?
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 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.
When can a Grievance be filed?
You may file a grievance within sixty (60) calendar days of the date of the circumstance giving rise to the grievance.
Expedited Grievance
You have the right to request an 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 health plan's decision to process your expedited reconsideration request as a standard request. In such cases, your Medicare Advantage health plan will respond to your grievance within twenty-four (24) hours of receipt.
Where can a Grievance be filed?
A grievance may be filed in writing directly to us.
Why file a Grievance?
You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information.
Grievance, Coverage Determinations and Appeals
Filing a grievance (making a complaint) about your prescription coverage
A grievance is a complaint other than one that involves a request for a coverage determination. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Grievances do not involve problems related to approving or paying for Medicare Part D drugs.
Some types of problems that might lead to filing a grievance include:
If you have any of these problems and want to make a complaint, it is called "filing a grievance."
Who may file a grievance
You or someone you name may file a grievance. The person you name would be your “representative.” You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you.
If you want someone to act for you who is not already authorized by the Court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. To learn how to name your representative, call UnitedHealthcare® Customer Service.
Filing a grievance with our plan
The process for making a complaint is different from the process for coverage decisions and appeals. If you have a complaint, you or your representative may call the phone number for Medicare Part D Grievances (for complaints about Medicare Part D drugs) listed on the back of your member ID card. We will try to resolve your complaint over the phone.
If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us.
UnitedHealthcare Appeals and Grievances Department Part C
P. O. Box 31364
Salt Lake City, UT 84131-0364
Fax: Fax/Expedited appeals only – 1-844-226-0356
OR
Call 1-877-614-0623 TTY 711
8 a.m. - 5 p.m. PT, Monday – Friday
UnitedHealthcare Appeals and Grievances Department Part D
Attn: Medicare Part D Appeals & Grievance Dept.
You may fax your written request toll-free to 1-877-960-8235.
Or Call 1-877-614-0623 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
If you ask for a written response, file a written grievance, or your complaint is related to quality of care, we will respond in writing.
If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.
Please be sure to include the words "fast", "expedited" or "24-hour review" on your request.
Please be sure to include the words "fast", "expedited" or "24-hour review" on your request.
Whether you call or write, you should contact Customer Service right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days.
If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. If we do not agree with some or all of your complaint or don't take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.
Review the Evidence of Coverage for additional details..
An initial coverage decision about your Part D drugs is called a “coverage decision.” A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.
In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under your plan, that isn't a coverage determination. You need to call or write to us to ask for a formal decision about the 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. Some covered drugs may have additional requirements or limits that help ensure safe, effective and affordable drug use. If there is a restriction for your drug, it usually means that you (or your doctor) will have to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you.
You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names in the plan's drug list. To find the plan's drug list go to View plans and pricing and enter your ZIP code. Choose one of the available plans in your area and view the plan details. You’ll find the form you need in the Helpful Resources section.
Some drugs covered by the Medicare Part D plan have "limited access" at network pharmacies because:
Requirements and limits apply to retail and mail service. These may include:
Prior Authorization (PA)
The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.
Quantity Limits (QL)
The plan will cover only a certain amount of this drug , or a cumulative amount across a category of drugs (such as opioids), for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.
Step Therapy (ST)
There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Medicare Part B or Medicare Part D Coverage Determination (B/D)
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.
NOTE: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.
IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN'S COVERAGE RULES
You can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.
Formulary Exceptions
Cost Sharing Exceptions
Generally, the plan will only approve your request for an exception if the alternative drugs included in the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.
Call the UnitedHealthcare Customer Service number to request a coverage determination (coverage decision). When requesting a formulary or tiering exception or asking for the plan to cover an additional amount of a drug with a quantity limit or asking for the plan to waive a step therapy requirement, a statement from your doctor supporting your request is required. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor's supporting statement (if required).
You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.
If you are a continuing member in the plan, you may notice that a formulary medication which you are currently taking is either not on the 2020 formulary or its cost-sharing or coverage is limited in the upcoming year.
If you are affected by a change in drug coverage you can:
In some situations, we will cover a one-time, temporary supply. During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. To initiate a coverage determination request, please contact UnitedHealthcare.
Have the following information ready when you call:
You may also request a coverage decision/exception by logging on to www.optumrx.com and submitting a request. If you are a new user with www.optumrx.com, you will need to register before you can access the Prior Authorization request tool. Once you have registered, you will find the Prior Authorization tool under the Health Tools Menu. Once your request has been submitted, we will attempt to contact your prescriber to get a supporting statement and/or additional clinical information needed to make a decision.
Download this form to request an exception:
To have your doctor make a request
Your doctor or provider can contact UnitedHealthcare at 1-800-711-4555 for the Prior Authorization department to submit a request, or fax toll-free to 1-844-403-1028. The plan's decision on your exception request will be provided to you by telephone or mail. In addition, the initiator of the request will be notified by telephone or fax.
Your doctor can also request a coverage decision by going to www.professionals.optumrx.com.
To inquire about the status of a coverage decision, contact UnitedHealthcare.
Please refer to your plan’s Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage document or your plan’s member handbook.
Note: Existing plan members who have already completed the coverage determination process for their medications in 2020 may not be required to complete this process again.
What happens if we deny your request?
If we deny your request, we will send you a written reply explaining the reasons for denial. If an initial decision does not give you all that you requested, you have the right to appeal the decision. See How to appeal a decision about your prescription coverage.
How to appoint a representative to help you with a coverage determination or an appeal.
The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case. Click here to find and download the CMS Appointment of Representation form.
Both you and the person you have named as an authorized representative must sign the representative form.
For Coverage Determinations
OptumRX Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Fax: 1-844-403-1028
For Appeals
Medicare Part D Appeals and Grievance Department
PO Box 6103, M/S CA 124-0197
Cypress, CA 90630-9948
Fax: 1-866-308-6294
If your prescribing doctor calls on your behalf, no representative form is required.
If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.
How to appeal a decision about your prescription coverage
Appeal Level 1 - You may ask us to review an adverse coverage decision we’ve issued to you, even if only part of our decision is not what you requested. An appeal to the plan about a Medicare Part D drug is also called a plan "redetermination."
Appeal Level 2 – If we reviewed your appeal at “Appeal Level 1” and did not decide in your favor, you have the right to appeal to the Independent Review Entity (IRE).
When we receive your request to review the adverse coverage determination, we give the request to people at our organization not involved in making the initial determination. This helps ensure that we give your request a fresh look.
To inquire about the status of an appeal, contact UnitedHealthcare.
UnitedHealthcare Coverage Determination Part C
P. O. Box 31364
Hot Springs, AR 71903-9675
Fax: Fax/Expedited appeals only – 1-501-262-7072
OR
Call 1-877-614-0623 TTY 711
8 a.m. - 5 p.m. PT, Monday – Friday
UnitedHealthcare Coverage Determination Part D
Attn: Medicare Part D Appeals & Grievance Dept.
PO Box 6103, M/S CA 124-0197
Cypress CA 90630-0023
Fax: Fax/Expedited appeals only 1-501-262-7072
Or Call 1-877-614-0623 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
Who may file your appeal of the coverage determination?
If you are appealing a coverage decision about a Medicare Part D drug, you, your authorized representative, or a prescriber (or his and her office staff) may file a standard appeal request or a fast appeal request.
How soon must you file your appeal?
You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.
How soon will we decide on your appeal?
For a standard decision regarding reimbursement for a Medicare Part D drug you have paid for and received and for standard appeal review requests for drugs you have not yet received:
We will give you our decision within 7 calendar days of receiving the pre-service appeal request and 14 days for a reimbursement request. If we do not give you our decision within 7/14 calendar days, your request will automatically go to Appeal Level 2 (Independent Review Entity).
For a fast decision about a Medicare Part D drug that you have not yet received.
We will give you our decision within 72 hours after receiving the appeal request. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2.
Next steps if the plan says "no"
If you asked for Medicare Part D drugs or payment for Medicare Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the Independent Review Entity (Appeal Level 2).
If you choose to appeal, you must send the appeal request to the Independent Review Entity (IRE). The decision you receive from the plan (Appeal Level 1) will tell you how to file the appeal, including who can file the appeal and how soon it must be filed. You must file your appeal within 60 days from the date on the letter you receive.
To obtain an aggregate number of the plan's grievances, appeals and exceptions please contact UnitedHealthcare.
The following information about your Medicare Part D Drug Benefit is available upon request:
2020 Quality assurance policies and procedures
The Utilization Management/Quality Assurance (UM/QA) program is designed to help ensure safe and appropriate use of prescription drugs covered under Medicare Part D. This program focuses on reducing adverse drug events and drug interactions, optimizing medication utilization, and providing incentives to reduce costs when medically appropriate. UnitedHealthcare offers the UM/QA program at no additional cost to its members and their providers.
Utilization management
The UM/QA program incorporates utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits and step therapy.
Quality assurance
As part of the UM/QA program, all prescriptions are screened by drug utilization review systems developed to detect and address the following clinical issues:
In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.
Your health plan must follow strict rules for how we identify, track, resolve and report all appeals and grievances. The following information applies to benefits provided by your Medicare benefit.
Appeals, Coverage Determinations and Grievances
Your Medicare Advantage health plan must follow strict rules for how they identify, track, resolve and report all appeals and grievances.
An appeal may be filed by any of the following:
What is an Appeal?
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.
When can an Appeal be filed?
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:
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.
Where can an Appeal be filed?
An appeal may be filed in writing directly to us. See the contact information below for appeals regarding services.
UnitedHealthcare Appeals and Grievances Department Part C
P. O. Box 31364
Salt Lake City, UT 84131-0364
Call: 1-888-867-5511
Available 8 a.m. to 8 p.m. local time, 7 days a week
Fax/Expedited Fax: 1-844-226-0356
An appeal may be filed in writing directly to us.
UnitedHealthcare Appeals and Grievances Department Part D
PO Box 6103, MS CA 124-0197
Cypress CA 90630-0023
Fax: Fax/Expedited appeals only – 1-877-960-8235
OR
Call 1-888-867-5511 TTY 711
Available 8 a.m. to 8 p.m. local time, 7 days a week
Why file an Appeal?
You may use the appeal procedure when you want a reconsideration of a decision (organization determination) that was made regarding a service or the amount of payment your Medicare Advantage health plan paid for a service.
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:
If your Medicare Advantage health plan or your Primary Care Provider 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 plus fourteen (14) calendar days, if an extention is taken, after receiving the request.
Who can file a Grievance?
A grievance may be filed by any of the following:
What is a Grievance?
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.
When can a Grievance be filed?
You may file a grievance at any time.
Expedited Grievance
You have the right to request an 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 reconsideration request as a standard request. In such cases, your Medicare Advantage health plan will respond to your grievance within twenty-four (24) hours of receipt.
Where can a Grievance be filed?
A grievance may be filed in writing or by phoning your Medicare Advantage health plan.
Why file a Grievance?
You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your Medicare Advantage health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information.
Grievance, Coverage Determinations and Appeals
Filing a grievance (making a complaint) about your prescription coverage
A grievance is a complaint other than one that involves a request for a coverage determination. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Grievances do not involve problems related to approving or paying for Medicare Part D drugs.
Some types of problems that might lead to filing a grievance include:
If you have any of these problems and want to make a complaint, it is called "filing a grievance."
You or someone you name may file a grievance. The person you name would be your "representative." You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you.
If you want someone to act for you who is not already authorized by the Court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. To learn how to name your representative, call UnitedHealthcare® Customer Service.
The process for making a complaint is different from the process for coverage decisions and appeals. If you have a complaint, you or your representative may call the phone number for Medicare Part D Grievances (for complaints about Medicare Part D drugs) listed on the back of your member ID card. We will try to resolve your complaint over the phone.
If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. Submit a written request for a grievance to Part C & D Grievances:
Part C Grievances
UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department
PO Box 31364
Salt Lake City, UT 84131-0364
Or
Fax/Expedited Fax: 1-844-226-0356
Or you can call us at: 1-888-867-5511
TTY 711.
Available 8 a.m. - 8 p.m. local time, 7 days a week
Part D Grievances UnitedHealthcare Part D Standard Appeals
Attn: Complaint and Appeals Department
P.O. Box 6103
MS CA 124-0197
Cypress, CA 90630-0023
Or
Expedited Fax: 1-877-960-8235
Or you can call us at: 1-888-867-5511
TTY 711.
Available 8 a.m. - 8 p.m.; local time, 7 days a week
If you ask for a written response, file a written grievance, or if your complaint is related to quality of care, we will respond in writing.
If you are making a complaint because we denied your request for a "fast coverage decision" or a "fast appeal," we will automatically give you a "fast" complaint. If you have a "fast" complaint, it means we will give you an answer within 24 hours.
Please be sure to include the words "fast", "expedited" or "24-hour review" on your request.
Whether you call or write, you should contact Customer Service right away. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days.
If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.
Review the Evidence of Coverage for additional details.
Coverage Determination
The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for prescription drugs, including problems related to payment. This is the process you use for issues such as whether a drug is covered or not and the way in which the drug is covered.
An initial coverage decision about your Part D drugs is called a “coverage determination.”, or simply put, a “coverage decision.” A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.
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. Some covered drugs may have additional requirements or limits that help ensure safe, effective and affordable drug use If there is a restriction for your drug, it usually means that you (or your doctor) will have to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you.
You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names in the plan's drug list. To find the plan's drug list go to View plans and pricing and enter your ZIP code. Choose one of the available plans in your area and view the plan details. You’ll find the form you need in the Helpful Resources section.
Some drugs covered by the Medicare Part D plan have "limited access" at network pharmacies because:
Requirements and limits apply to retail and mail service. These may include:
Prior Authorization (PA)
The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.
Quantity Limits (QL)
The plan will cover only a certain amount of this drug , or a cumulative amount across a category of drugs (such as opioids), for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.
Step Therapy (ST)
There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Medicare Part B or Medicare Part D Coverage Determination (B/D)
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.
NOTE: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.
IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN'S COVERAGE RULES
You can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.
Formulary Exceptions
Cost Sharing Exceptions
Generally, the plan will only approve your request for an exception if the alternative drugs included in the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.
Call the UnitedHealthcare Customer Service number to request a coverage determination (coverage decision). When requesting a formulary or tiering exception or asking for the plan to cover an additional amount of a drug with a quantity limit or asking for the plan to waive a step therapy requirement, a statement from your doctor supporting your request is required. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor's supporting statement (if required).
You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.
If you are a continuing member in the plan, you may notice that a formulary medication which you are currently taking is either not on the 2020 formulary or its cost-sharing or coverage is limited in the upcoming year.
If you are affected by a change in drug coverage you can:
In some situations, we will cover a one-time, temporary supply. During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. To initiate a coverage determination request, please contact UnitedHealthcare.
Have the following information ready when you call:
You may also request a coverage decision/exception by logging on to www.optumrx.com and submitting a request. If you are a new user with www.optumrx.com, you will need to register before you can access the Prior Authorization request tool. Once you have registered, you will find the Prior Authorization tool under the Health Tools Menu. Once your request has been submitted, we will attempt to contact your prescriber to get a supporting statement and/or additional clinical information needed to make a decision.
Download this form to request an exception:
To have your doctor make a request
Your doctor or provider can contact UnitedHealthcare at 1-800-711-4555 for the Prior Authorization department to submit a request, or fax toll-free to 1-844-403-1028. The plan's decision on your exception request will be provided to you by telephone or mail. In addition, the initiator of the request will be notified by telephone or fax.
Your doctor can also request a coverage decision by going to www.professionals.optumrx.com.
To inquire about the status of a coverage decision, contact UnitedHealthcare.
Please refer to your plan’s Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage document or your plan’s member handbook.
Note: Existing plan members who have already completed the coverage determination process for their medications in 2020 may not be required to complete this process again.
What happens if we deny your request?
If we deny your request, we will send you a written reply explaining the reasons for denial. If an initial decision does not give you all that you requested, you have the right to appeal the decision. See How to appeal a decision about your prescription coverage.
How to appoint a representative to help you with a coverage determination or an appeal.
The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case. Download the representative form.
Both you and the person you have named as an authorized representative must sign the representative form. This statement must be sent to
For Coverage Determinations
Mail: OptumRx Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Fax: 1-844-403-1028
For Appeals
Mail: Medicare Part D Appeals and Grievance Department
PO Box 6103, M/S CA 124-0197
Cypress, CA 90630-9948
Fax: 1-866-308-6294
If your prescribing doctor calls on your behalf, no representative form is required.
If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.
How to appeal a decision about your prescription coverage
Appeal Level 1 - You may ask us to review an adverse coverage decision we’ve issued to you, even if only part of our decision is not what you requested. An appeal to the plan about a Medicare Part D drug is also called a plan "redetermination."
Appeal Level 2 – If we reviewed your appeal at "Appeal Level 1" and did not decide in your favor, you have the right to appeal to the Independent Review Entity (IRE).
When we receive your request to review the adverse coverage determination, we give the request to people at our organization not involved in making the initial determination. This helps ensure that we give your request a fresh look.
Send the letter or the Redetermination Request Form to the Medicare Part D Appeals and Grievance Department P.O. Box 6103 MS CA 124-097 Cypress, CA 90630-0023. You may also fax your letter of appeal to the Medicare Part D Appeals and Grievances Department toll-free at 1-877-960-8235. You must mail your letter within 60 days of the date the adverse determination was issues, or within 60 days from the date of the denial of reimbursement request. If you missed the 60-day deadline, you may still file your appeal if you provide a valid reason for missing the deadline. Or you can call us at: 1-888-867-5511 TTY 711. Available 8 a.m. - 8 p.m. local time, 7 days a week.
To inquire about the status of an appeal, contact UnitedHealthcare.
UnitedHealthcare Coverage Determination Part C
P. O. Box 29675
Hot Springs, AR 71903-9675
Call: 1-888-867-5511 TTY 711
Available 8 a.m. to 8 p.m. local time, 7 days a week
Fax/Expedited Fax: 1-501-262-7070
An appeal may be filed in writing directly to us.
UnitedHealthcare Coverage Determination Part D
P. O. Box 29675
Hot Springs, AR 71903-9675
Call: 1-888-867-5511 TTY 711
Available 8 a.m. to 8 p.m. local time, 7 days a week
Fax/Expedited Fax: 1-501-262-7070
Who may file your appeal of the coverage determination?
If you are appealing a coverage decision about a Medicare Part D drug, you, your authorized representative, or a prescriber (or his and her office staff) may file a standard appeal request or a fast appeal request.
How soon must you file your appeal?
You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.
How soon will we decide on your appeal?
For a standard decision regarding reimbursement for a Medicare Part D drug you have paid for and received and for standard appeal review requests for drugs you have not yet received:
We will give you our decision within 7 calendar days of receiving the pre-service appeal request and <14> days for a reimbursement request. If we do not give you our decision within 7/14 calendar days, your request will automatically go to Appeal Level 2 (Independent Review Entity).
For a fast decision about a Medicare Part D drug that you have not yet received.
We will give you our decision within 72 hours after receiving the appeal request. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2.
Next steps if the plan says "no"
If you asked for Medicare Part D drugs or payment for Medicare Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the Independent Review Entity (Appeal Level 2).
If you choose to appeal, you must send the appeal request to the Independent Review Entity (IRE). The decision you receive from the plan (Appeal Level 1) will tell you how to file the appeal, including who can file the appeal and how soon it must be filed. You must file your appeal within 60 days from the date on the letter you receive.
To obtain an aggregate number of the plan's grievances, appeals and exceptions please contact UnitedHealthcare.
The following information about your Medicare Part D Drug Benefit is available upon request:
Quality assurance policies and procedures
The Utilization Management/Quality Assurance (UM/QA) program is designed to help ensure safe and appropriate use of prescription drugs covered under Medicare Part D. This program focuses on reducing adverse drug events and drug interactions, optimizing medication utilization, and providing incentives to reduce costs when medically appropriate. UnitedHealthcare offers the UM/QA program at no additional cost to its members and their providers.
Utilization management
The UM/QA program incorporates utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits and step therapy.
Quality assurance
As part of the UM/QA program, all prescriptions are screened by drug utilization review systems developed to detect and address the following clinical issues:
In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.
Who can file an Appeal?
An appeal may be filed by any of the following:
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.
The standard resolution time frame for completion is 30 calendar days for a pre-service appeal. If we need more time, we may take a 14 day calendar day extension. If we take an extension, we will let you know.
If your appeal is regarding a Part B drug which you have not yet received, the timeframe from completion is 7 calendar days. An extension for Part B drug appeals is not allowed.
You may file a Part C/Medical 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:
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.
Where can an Appeal be filed?
An appeal may be filed in writing directly to us.
UnitedHealthcare Appeals and Grievances Department Part C/Medical
P. O. Box 31364
Salt Lake City, UT 84131-0364
Fax: Fax/Expedited appeals only – 1-844-226-0356
OR
Call 1-800-514-4911 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
An appeal may be filed in writing directly to us.
UnitedHealthcare Appeals and Grievances Department Part D
PO Box 6103, MS CA 124-0197Fax: Fax/Expedited appeals only – 1-877-960-8235
OR
Call 1-800-514-4911 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
Why file an Appeal?
You may use the appeal procedure when you want a reconsideration of a decision (organization determination) that was made regarding a service or the amount of payment your health plan paid for a service.
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:
If your health plan or your Primary Care Provider 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 plus 14 calendar days, if an extension is taken, after receiving the request.
Grievances
Who can file a Grievance?
A grievance may be filed by any of the following:
What is a Grievance?
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 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.
When can a Grievance be filed?
You may file a grievance within ninety (90) calendar days for Part C/Medical and sixty (60) calendar days for Part D after the problem happened.
You may file a Part C/medical grievance at any time. Grievances regarding your drug benefit (Part D) must be filed within sixty (60) days after the problem happened.
Expedited Grievance
You have the right to request an 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 reconsideration request as a standard request. In such cases, your Medicare Advantage health plan will respond to your grievance within twenty-four (24) hours of receipt.
Where can a Grievance be filed?
A grievance may be filed in writing directly to us.
UnitedHealthcare Appeals and Grievances Department Part C/Medical
P. O. Box 31364
Salt Lake City, UT 84131-0364
Fax: Fax/Expedited appeals only – 1-844-226-0356
OR
Call 1-800-514-4911 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
A grievance may be filed in writing directly to us.
UnitedHealthcare Appeals and Grievances Department Part D
PO Box 6103, MS CA 124-0197Fax: Fax/Expedited appeals only – 1-877-960-8235
OR
Call 1-800-514-4911 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
Why file a Grievance?
You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your Medicare Advantage health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information.
Part D - Grievance, Coverage Determinations and Appeals
Filing a grievance (making a complaint) about your prescription coverage
A grievance is a complaint other than one that involves a request for a coverage determination. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Grievances do not involve problems related to approving or paying for Medicare Part D drugs.
Some types of problems that might lead to filing a grievance include:
If you have any of these problems and want to make a complaint, it is called "filing a grievance."
Who may file a Grievance
You or someone you name may file a grievance. The person you name would be your “representative.” You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you.
If you want someone to act for you who is not already authorized by the Court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. To learn how to name your representative, call UnitedHealthcare® Customer Service.
Filing a Grievance with our plan
The process for making a complaint is different from the process for coverage decisions and appeals. If you have a complaint, you or your representative may call the phone number for Medicare Part D Grievances (for complaints about Medicare Part D drugs) listed on the back of your member ID card. We will try to resolve your complaint over the phone.
If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us.
Submit a written request for a Part C/Medical and Part D grievance to:
UnitedHealthcare Appeals and Grievances Department Part C/Medical
P. O. Box 31364
Salt Lake City, UT 84131-0364
Fax: Fax/Expedited appeals only – 1-844-226-0356
OR
Call 1-800-514-4911 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
If you ask for a written response, file a written grievance, or your complaint is related to quality of care, we will respond in writing.
If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.
You may contact UnitedHealthcare to file an expedited Grievance. Please be sure to include the words "fast," "expedited" or "24-hour review" on your request.
Please be sure to include the words "fast", "expedited" or "24-hour review" on your request.
Whether you call or write, you should contact Customer Service right away. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days.
If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. If we do not agree with some or all of your complaint or don't take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.
Review the Evidence of Coverage for additional details.'
An initial coverage decision about your Part D drugs is called a “coverage decision.” A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.
In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under your plan, that isn't a coverage determination. You need to call or write to us to ask for a formal decision about the 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. Some covered drugs may have additional requirements or limits that help ensure safe, effective and affordable drug use. If there is a restriction for your drug, it usually means that you (or your doctor) will have to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you . You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names in the plan's drug list. To find the plan's drug list go to View plans and pricing and enter your ZIP code. Choose one of the available plans in your area and view the plan details. You’ll find the form you need in the Helpful Resources section.
Some drugs covered by the Medicare Part D plan have "limited access" at network pharmacies because:
Requirements and limits apply to retail and mail service. These may include:
Prior Authorization (PA)
The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.
Quantity Limits (QL)
The plan will cover only a certain amount of this drug, or a cumulative amount across a category of drugs (such as opioids), for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.
Step Therapy (ST)
There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Medicare Part B or Medicare Part D Coverage Determination (B/D)
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.
NOTE: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.
IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN'S COVERAGE RULES
You can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.
Formulary Exceptions
You can ask the plan to cover your drug even if it is not on the plan's drug list (formulary).
How to request a coverage determination (including benefit exceptions)
Call the UnitedHealthcare Customer Service number to request a coverage determination (coverage decision). When requesting a formulary exception or asking for the plan to cover an additional amount of a drug with a quantity limit or asking for the plan to waive a step therapy requirement, a statement from your doctor supporting your request is required. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor's supporting statement (if required).
You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.
If you are a continuing member in the plan, you may notice that a formulary medication which you are currently taking is either not on the 2020 formulary or its coverage is limited in the upcoming year.
If you are affected by a change in drug coverage you can:
In some situations, we will cover a one-time, temporary supply. During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. To initiate a coverage determination request, please contact UnitedHealthcare.
Have the following information ready when you call:
You may also request a coverage decision/exception by logging on to www.optumrx.com and submitting a request. If you are a new user with www.optumrx.com, you will need to register before you can access the Prior Authorization request tool. Once you have registered, you will find the Prior Authorization tool under the Health Tools Menu. Once your request has been submitted, we will attempt to contact your prescriber to get a supporting statement and/or additional clinical information needed to make a decision.
Download this form to request an exception:
To have your doctor make a request
Your doctor or provider can contact UnitedHealthcare at 1-800-711-4555 for the Prior Authorization department to submit a request, or fax toll-free to 1-844-403-1028. The plan's decision on your exception request will be provided to you by telephone or mail. In addition, the initiator of the request will be notified by telephone or fax.
Your doctor can also request a coverage decision by going to www.professionals.optumrx.com.
To inquire about the status of a coverage decision, contact UnitedHealthcare.
Please refer to your plan’s Appeals and Grievance process located in Chapter 8: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage document.
Note: Existing plan members who have already completed the coverage determination process for their medications in 2020 may not be required to complete this process again.
What happens if we deny your request?
If we deny your request, we will send you a written reply explaining the reasons for denial. If an initial decision does not give you all that you requested, you have the right to appeal the decision. See How to appeal a decision about your prescription coverage.
How to appoint a representative to help you with a coverage determination or an appeal.
The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case. Click here to find and download the CMS Appointment of Representation form.
Both you and the person you have named as an authorized representative must sign the representative form. This statement must be sent to
For Coverage Determinations
OptumRX Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Fax: 1-844-403-1028
For Appeals
Medicare Part D Appeals and Grievance Department
PO Box 6103, M/S CA 124-0197
Cypress, CA 90630-9948
Fax: 1-866-308-6294
If your prescribing doctor calls on your behalf, no representative form is required. Or you can call us at: 1-888-867-5511, TTY 711, Available 8 a.m. - 8 p.m. local time, 7 days a week.
If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.
How to appeal a decision about your prescription coverage
Appeal Level 1 - You may ask us to review an adverse coverage decision we’ve issued to you, even if only part of our decision is not what you requested. An appeal to the plan about a Medicare Part D drug is also called a plan "redetermination."
Appeal Level 2 – If we reviewed your appeal at “Appeal Level 1” and did not decide in your favor, you have the right to appeal to the Independent Review Entity (IRE).
When we receive your request to review the adverse coverage determination, we give the request to people at our organization not involved in making the initial determination. This helps ensure that we give your request a fresh look.
To inquire about the status of an appeal, contact UnitedHealthcare.
Submit a written request for an appeal to:
An appeal may be filed in writing directly to us.
UnitedHealthcare Coverage Determination Part C/Medical and Part D
P. O. Box 5250
Kingston, NY 12402-5250
Fax: Fax/Expedited appeals only – 1-501-262-7072
OR
Call 1-800-514-4911 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
Who may file your appeal of the coverage determination?
If you are appealing a coverage decision about a Medicare Part D drug, you, your authorized representative, or a prescriber (or his and her office staff) may file a standard appeal request or a fast appeal request.
How soon must you file your appeal?
You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.
How soon will we decide on your appeal?
For a standard decision regarding reimbursement for a Medicare Part D drug you have paid for and received and for standard appeal review requests for drugs you have not yet received:
We will give you our decision within 7 calendar days of receiving the pre-service appeal request and 14 days for a reimbursement request. If we do not give you our decision within 7/14 calendar days, your request will automatically go to Appeal Level 2 (Independent Review Entity).
For a fast decision about a Medicare Part D drug that you have not yet received.
We will give you our decision within 72 hours after receiving the appeal request. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2.
Next steps if the plan says "no"
If you asked for Medicare Part D drugs or payment for Medicare Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the Independent Review Entity (Appeal Level 2).
If you choose to appeal, you must send the appeal request to the Independent Review Entity (IRE). The decision you receive from the plan (Appeal Level 1) will tell you how to file the appeal, including who can file the appeal and how soon it must be filed. You must file your appeal within <60> days from the date on the letter you receive.
To obtain an aggregate number of the plan's grievances, appeals and exceptions please contact UnitedHealthcare.
The following information about your Medicare Part D Drug Benefit is available upon request:
Quality assurance policies and procedures
The Utilization Management/Quality Assurance (UM/QA) program is designed to help ensure safe and appropriate use of prescription drugs covered under Medicare Part D. This program focuses on reducing adverse drug events and drug interactions, optimizing medication utilization, and providing incentives to reduce costs when medically appropriate. UnitedHealthcare offers the UM/QA program at no additional cost to its members and their providers.
Utilization management
The UM/QA program incorporates utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits and step therapy.
Quality assurance
As part of the UM/QA program, all prescriptions are screened by drug utilization review systems developed to detect and address the following clinical issues:
In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.
Your Medicare Advantage health plan must follow strict rules for how they identify, track, resolve and report all appeals and grievances.
For information regarding your Medicaid benefit and the appeals and grievances process, please access your Medicaid Plan’s Member Handbook.
Who can file an Appeal?
An appeal may be filed by any of the following:
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 may file a Part C 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:
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.
Where can an Appeal be filed?
An appeal may be filed in writing directly to us.
UnitedHealthcare Appeals and Grievances Department Part C
P. O. Box 31364
Salt Lake City, UT 84131-0364
Fax: Fax/Expedited appeals only – 1-844-226-0356
OR
Call 1-877-517-7113 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
An appeal may be filed in writing directly to us.
UnitedHealthcare Appeals and Grievances Department Part D
PO Box 6103, MS CA 124-0197Fax: Fax/Expedited appeals only – 1-866-308-6294
OR
Call 1-877-514-4912 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
Why file an Appeal?
You may use the appeal procedure when you want a reconsideration of a decision (organization determination) that was made regarding a service or the amount of payment your Medicare Advantage health plan paid for a service.
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:
If your health plan or your Primary Care Provider 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 plus 14 calendar days, if an extension is taken, after receiving the request.
Grievances
Who can file a Grievance?
A grievance may be filed by any of the following:
What is a Grievance?
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.
When can a Grievance be filed?
You may file a verbal grievance by calling customer service or a written grievance by writing to the plan within sixty (60) calendar days of the date of the circumstance giving rise to the grievance.
Expedited Grievance
You have the right to request an 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 reconsideration request as a standard request. In such cases, your Medicare Advantage health plan will respond to your grievance within twenty-four (24) hours of receipt.
Where can a Grievance be filed?
A grievance may be filed verbally or in writing. A verbal grievance may be filed by calling the Customer Service number on the back of your ID card. For complaints about Part D Drugs you may also call the phone number for Medicare Part D Grievances listed on the back of your ID Card. If we were unable to resolve your complaint over the phone you may file written complaint.
A written Grievance may be filed by writing to the plan at the address listed in the Grievance, Coverage Determinations and Appeals section below.
Why file a Grievance?
You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your Medicare Advantage health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information.
Prievance, Coverage Determinations and Appeals
Filing a grievance (making a complaint) about your prescription coverage
A grievance is a complaint other than one that involves a request for a coverage determination. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Grievances do not involve problems related to approving or paying for Medicare Part D drugs.
Some types of problems that might lead to filing a grievance include:
If you have any of these problems and want to make a complaint, it is called "filing a grievance."
Who may file a grievance
You or someone you name may file a grievance. The person you name would be your “representative.” You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you.
If you want someone to act for you who is not already authorized by the Court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. To learn how to name your representative, call UnitedHealthcare® Customer Service.
Filing a grievance with our plan
The process for making a complaint is different from the process for coverage decisions and appeals. If you have a complaint, you or your representative may call the phone number for Medicare Part D Grievances (for complaints about Medicare Part D drugs) listed on the back of your member ID card. We will try to resolve your complaint over the phone.
If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. Submit a written request for a Part C and Part D grievance to:
Submit a written request for a Part C and Part D grievance to:
UnitedHealthcare Appeals and Grievances Department Part C
P. O. Box 31364
Salt Lake City, UT 84131-0364
Fax: Fax/Expedited appeals only – 1-844-226-0356
OR
Call 1-877-517-7113 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
A grievance may be filed in writing directly to us.
UnitedHealthcare Appeals and Grievances Department Part D
P.O. Box 6106, MS CA124-0197
Cypress, CA 90630-0023
Fax: Fax/Expedited appeals only – 1-866-308-6294
OR
Call 1-877-514-4912 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
If you ask for a written response, file a written grievance, or your complaint is related to quality of care, we will respond in writing.
If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast” complaint. If you have a "fast" complaint, it means we will give you an answer within 24 hours.
Please be sure to include the words "fast", "expedited" or "24-hour review" on your request.
Whether you call or write, you should contact Customer Service right away. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days.
If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. If we do not agree with some or all of your complaint or don't take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.
Review the Evidence of Coverage for additional details.
An initial coverage decision about your Part D drugs is called a “coverage decision.” A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.
In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under your plan, that isn't a coverage determination. You need to call or write to us to ask for a formal decision about the 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. Some covered drugs may have additional requirements or limits that help ensure safe, effective and affordable drug use. If there is a restriction for your drug, it usually means that you (or your doctor) will have to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you . You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names in the plan's drug list. To find the plan's drug list go to View plans and pricing and enter your ZIP code. Choose one of the available plans in your area and view the plan details. You’ll find the form you need in the Helpful Resources section.
Some drugs covered by the Medicare Part D plan have "limited access" at network pharmacies because:
Requirements and limits apply to retail and mail service. These may include:
Prior Authorization (PA)
The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.
Quantity Limits (QL)
The plan will cover only a certain amount of this drug, or a cumulative amount across a category of drugs (such as opioids), for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.
Step Therapy (ST)
There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Medicare Part B or Medicare Part D Coverage Determination (B/D)
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.
NOTE: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.
IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN'S COVERAGE RULES
You can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.
Formulary Exceptions
Cost Sharing Exceptions
Generally, the plan will only approve your request for an exception if the alternative drugs included in the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.
Call the UnitedHealthcare Customer Service number to request a coverage determination (coverage decision). When requesting a formulary or tiering exception or asking for the plan to cover an additional amount of a drug with a quantity limit or asking for the plan to waive a step therapy requirement, a statement from your doctor supporting your request is required. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor's supporting statement (if required).
You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.
If you are a continuing member in the plan, you may notice that a formulary medication which you are currently taking is either not on the 2020 formulary or its cost-sharing or coverage is limited in the upcoming year.
If you are affected by a change in drug coverage you can:
In some situations, we will cover a one-time, temporary supply. During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. To initiate a coverage determination request, please contact UnitedHealthcare.
Have the following information ready when you call:
You may also request a coverage decision/exception by logging on to www.optumrx.com and submitting a request. If you are a new user with www.optumrx.com, you will need to register before you can access the Prior Authorization request tool. Once you have registered, you will find the Prior Authorization tool under the Health Tools Menu. Once your request has been submitted, we will attempt to contact your prescriber to get a supporting statement and/or additional clinical information needed to make a decision.
Download this form to request an exception:
To have your doctor make a request
Your doctor or provider can contact UnitedHealthcare at 1-800-711-4555 for the Prior Authorization department to submit a request, or fax toll-free to 1-844-403-1028. The plan's decision on your exception request will be provided to you by telephone or mail. In addition, the initiator of the request will be notified by telephone or fax.
Your doctor can also request a coverage decision by going to www.professionals.optumrx.com.
To inquire about the status of a coverage decision, contact UnitedHealthcare.
Please refer to your plan’s Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage document or your plan’s member handbook.
Note: Existing plan members who have already completed the coverage determination process for their medications in 2020 may not be required to complete this process again.
What happens if we deny your request?
If we deny your request, we will send you a written reply explaining the reasons for denial. If an initial decision does not give you all that you requested, you have the right to appeal the decision. See How to appeal a decision about your prescription coverage.
How to appoint a representative to help you with a coverage determination or an appeal.
The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case. Click here to find and download the CMS Appointment of Representation form.
Both you and the person you have named as an authorized representative must sign the representative form.
For Coverage Determinations
OptumRX Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Fax: 1-844-403-1028
For Appeals
Medicare Part D Appeals and Grievance Department
PO Box 6103, M/S CA 124-0197
Cypress, CA 90630-9948
Fax: 1-866-308-6294
If your prescribing doctor calls on your behalf, no representative form is required.
If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.
How to appeal a decision about your prescription coverage
Appeal Level 1 - You may ask us to review an adverse coverage decision we’ve issued to you, even if only part of our decision is not what you requested. An appeal to the plan about a Medicare Part D drug is also called a plan "redetermination."
Appeal Level 2 – If we reviewed your appeal at “Appeal Level 1” and did not decide in your favor, you have the right to appeal to the Independent Review Entity (IRE).
When we receive your request to review the adverse coverage determination, we give the request to people at our organization not involved in making the initial determination. This helps ensure that we give your request a fresh look.
To inquire about the status of an appeal, contact UnitedHealthcare.
Submit a written request for a Part C and Part D grievance to:
UnitedHealthcare Coverage Determination Part C
P. O. Box 29675
Hot Springs, AZ 71903-9675
Fax: Fax/Expedited appeals only – 1-501-262-7072
OR
Call 1-877-514-4912 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
An appeal may be filed in writing directly to us.
UnitedHealthcare Coverage Determination Part D
P. O. Box 29675
Hot Springs, AZ 71903-9675
Fax: Fax/Expedited appeals only – 1-501-262-7072
OR
Call 1-877-514-4912 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
Who may file your appeal of the coverage determination?
If you are appealing a coverage decision about a Medicare Part D drug, you, your authorized representative, or a prescriber (or his and her office staff) may file a standard appeal request or a fast appeal request.
How soon must you file your appeal?
You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.
How soon will we decide on your appeal?
For a standard decision regarding reimbursement for a Medicare Part D drug you have paid for and received and for standard appeal review requests for drugs you have not yet received:
We will give you our decision within 7 calendar days of receiving the pre-service appeal request and 14 days for a reimbursement request. If we do not give you our decision within 7/14 calendar days, your request will automatically go to Appeal Level 2 (Independent Review Entity).
For a fast decision about a Medicare Part D drug that you have not yet received.
We will give you our decision within 72 hours after receiving the appeal request. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2.
Next steps if the plan says "no"
If you asked for Medicare Part D drugs or payment for Medicare Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the Independent Review Entity (Appeal Level 2).
If you choose to appeal, you must send the appeal request to the Independent Review Entity (IRE). The decision you receive from the plan (Appeal Level 1) will tell you how to file the appeal, including who can file the appeal and how soon it must be filed. You must file your appeal within 60 days from the date on the letter you receive.
To obtain an aggregate number of the plan's grievances, appeals and exceptions please contact UnitedHealthcare.
The following information about your Medicare Part D Drug Benefit is available upon request:
Quality assurance policies and procedures
The Utilization Management/Quality Assurance (UM/QA) program is designed to help ensure safe and appropriate use of prescription drugs covered under Medicare Part D. This program focuses on reducing adverse drug events and drug interactions, optimizing medication utilization, and providing incentives to reduce costs when medically appropriate. UnitedHealthcare offers the UM/QA program at no additional cost to its members and their providers.
Utilization management
The UM/QA program incorporates utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits and step therapy.
Quality assurance
As part of the UM/QA program, all prescriptions are screened by drug utilization review systems developed to detect and address the following clinical issues:
In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.
Your health plan must follow strict rules for how it identifies, tracks, resolves and reports all appeals and grievances.
Prior Authorizations /Formulary Exceptions
Medicare Part D prior authorization forms list
Prescription Drugs - Not Covered by Medicare Part D
While most of your prescription drugs will be covered by Medicare Part D, there are a few drugs that are not covered by Medicare Part D but are covered by UnitedHealthcare® Connected™ for MyCare Ohio. You can view our plan's List of Covered Drugs on our website at www.myuhc.com/communityplan. Drugs with an asterisk are not covered by Medicare Part D but are covered by UnitedHealthcare® Connected™ for MyCare Ohio (Medicare-Medicaid Plan). You do not have any co-pays for non-Part D drugs covered by our plan.
Please note that our list of medications that require prior authorization, formulary exceptions or coverage determinations can change.
Submit a Pharmacy Prior Authorization. Formulary Exception or Coverage Determination Request to OptumRx.
Submit a Pharmacy Prior Authorization Request, Forumulary Exception or Coverage Determination electronically to OptumRx.
Who can file an Appeal?
An appeal may be filed by any of the following:
What is an Appeal?
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 health plan pays or will pay for a service or the amount you must pay for a service.
When can an Appeal be filed?
You may file an appeal within ninety (90) calendar days of the date of the notice of the initial coverage decision. For example, you may file an appeal for any of the following reasons:
Note: The ninety (90) day limit may be extended for good cause. Include in your written request the reason why you could not file within the ninety (90) day timeframe.
If you are appealing because you were told that a service you are getting will be reduced or stopped, you have a shorter timeframe to appeal if you want us to continue covering that service while the appeal is processing. For more information, please see your Member Handbook
In most cases, you must file your appeal with the Health Plan. However, if your problem is about a service or item covered primarily by Medicaid or both Medicare and Medicaid, you can request a State Hearing which is filed with the Bureau of State Hearings.
To file a State Hearing, your request must be made within 90 calendar days of receiving the notice of your State Hearing rights. The 90 calendar days begins on the day after the mailing date on the notice. If you have a good reason for being late the Bureau of State Hearings may extend this deadline for you.
For more information regarding State Hearings, please see your Member Handbook
Where can an Appeal be filed?
An appeal may be filed by calling us at 1-877-542-9236 (TTY 711) 8 a.m. to 8p.m. local time, Monday through Friday (voicemail available 24 hours a day/7 days a week) writing directly to us, calling us or submitting a form electronically via fax.
How do I Start an Appeal?
To start your appeal, you, your doctor or other provider, or your representative must contact us. You can call us at 1-877-542-9236 (TTY 7-1-1), 8 a.m. – 8 p.m. local time, Monday – Friday.
You can submit a request to the following address:
Part D Appeals:
UnitedHealthcare Community Plan
Attn: Part D Standard Appeals
P.O. Box 6103
Cypress, CA 90630-9948
Standard Fax: 1-877-960-8235
Part C Appeals:
Write of us at the following address:
UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department:
P.O. Box 31364
Salt Lake City, UT 84131 0364
Expedited Fax: 801-994-1349
Standard Fax: 801-994-1082
Why file an Appeal?
You may use the appeal procedure when you want a reconsideration of a decision (organization determination) that was made regarding a service or the amount of payment your health plan paid for a service.
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:
If your Medicare Advantage health plan or your Primary Care Provider 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 plus 14 calendar days, if an extension is taken, after receiving the request.
Coverage Determination
Asking for a coverage determination (coverage decision)
The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for prescription drugs, including problems related to payment. This is the process you use for issues such as whether a drug is covered or not and the way in which the drug is covered.
An initial coverage decision about your Part D drugs is called a "coverage determination.", or simply put, a "coverage decision." A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.
Drug requirements and limitations
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. Some covered drugs may have additional requirements or limits that help ensure safe, effective and affordable drug use. And some drugs may require a coverage determination to verify whether they are covered by the Medicare Part D plan. The coverage determination process allows you or your prescriber to request coverage of drugs with additional requirements or ask for exceptions to your benefits.
You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names in the plan's drug list. To find the plan's drug list go to the 'Find a Drug' Look Up Page and download your plan's formulary.
Some drugs covered by the Medicare Part D plan have "limited access" at network pharmacies because:
Requirements and limits apply to retail and mail service. These may include:
Prior Authorization (PA)
The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.
Quantity Limits (QL)
The plan will cover only a certain amount of this drug for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.
Step Therapy (ST)
There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Medicare Part B or Medicare Part D Coverage Determination (B/D)
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.
NOTE: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.
IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN'S COVERAGE RULES
You can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.
Formulary Exceptions
Cost Sharing Exceptions
Generally, the plan will only approve your request for an exception if the alternative drugs included in the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.
How to request a coverage determination (including benefit exceptions)
Call the UnitedHealthcare Customer Service number to request a coverage determination (coverage decision). When requesting a formulary or tiering exception or asking for the plan to cover an additional amount of a drug with a quantity limit or asking for the plan to waive a step therapy requirement, a statement from your doctor supporting your request is required. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor's supporting statement (if required).
You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.
If you are a continuing member in the plan, you may notice that a formulary medication which you are currently taking is either not on the 2020 formulary or its cost-sharing or coverage is limited in the upcoming year.
If you are affected by a change in drug coverage you can:
In some situations, we will cover a one-time, temporary supply. During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. To initiate a coverage determination request, please contact UnitedHealthcare.
Have the following information ready when you call:
You may also request a coverage decision/exception by logging on to www.optumrx.com and submitting a request. If you are a new user with www.optumrx.com, you will need to register before you can access the Prior Authorization request tool. Once you have registered, you will find the Prior Authorization tool under the Health Tools Menu. Once your request has been submitted, we will attempt to contact your prescriber to get a supporting statement and/or additional clinical information needed to make a decision.
Download this form to request an exception:
To have your doctor make a request
Your doctor or provider can contact UnitedHealthcare at 1-800-711-4555 for the Prior Authorization department to submit a request, or fax toll-free to 1-844-403-1028. The plan's decision on your exception request will be provided to you by telephone or mail. In addition, the initiator of the request will be notified by telephone or fax.
Your doctor can also request a coverage decision by going to www.professionals.optumrx.com.
To inquire about the status of a coverage decision, contact UnitedHealthcare.
Please refer to your plan’s Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage document or your plan’s member handbook.
Note: Existing plan members who have already completed the coverage determination process for their medications in 2020 may not be required to complete this process again.
What happens if we deny your request?
If we deny your request, we will send you a written reply explaining the reasons for denial. If an initial decision does not give you all that you requested, you have the right to appeal the decision. See How to appeal a decision about your prescription coverage.
How to appoint a representative to help you with a coverage determination or an appeal.
The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case. Click here to find and download the CMS Appointment of Representation form.
Both you and the person you have named as an authorized representative must sign the representative form.
For Coverage Determinations
OptumRX Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Fax: 1-844-403-1028
For Appeals
Medicare Part D Appeals and Grievance Department
PO Box 6103, M/S CA 124-0197
Cypress, CA 90630-9948
Fax: 1-866-308-6294
If your prescribing doctor calls on your behalf, no representative form is required.
Making an appeal
If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.
How to appeal a decision about your prescription coverage
Appeal Level 1 - You may ask us to review an adverse coverage decision we've issued to you, even if only part of our decision is not what you requested. An appeal to the plan about a Medicare Part D drug is also called a plan "redetermination."
Appeal Level 2 – If we reviewed your appeal at "Appeal Level 1" and did not decide in your favor, you have the right to appeal to the Independent Review Entity (IRE).
When we receive your request to review the adverse coverage determination, we give the request to people at our organization not involved in making the initial determination. This helps ensure that we give your request a fresh look.
To file an appeal:
Send the letter or the Redetermination Request Form to the
Part D Appeals:
UnitedHealthcare Community Plan
Attn: Part D Standard Appeals
P.O. Box 6103
Cypress, CA 90630-9948
Standard Fax: 877-960-8235
Part C Appeals:
Grievances and Medical (Non-Drug) Appeals:
Write of us at the following address:
UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department:
P.O. Box 31364
Salt Lake City, UT 84131 0364
Expedited Fax: 801-994-1349
Standard Fax: 801-994-1082
To inquire about the status of an appeal, contact UnitedHealthcare.
Who may file your appeal of the coverage determination?
If you are appealing a coverage decision about a Medicare Part D drug, you, your authorized representative, or a prescriber (or his and her office staff) may file a standard appeal request or a fast appeal request.
How soon must you file your appeal?
You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.
How soon will we decide on your appeal?
For a standard decision regarding reimbursement for a Medicare Part D drug you have paid for and received and for standard appeal review requests for drugs you have not yet received:
We will give you our decision within 7 calendar days of receiving the appeal request. If we do not give you our decision within 7 calendar days, your request will automatically go to Appeal Level 2 (Independent Review Entity).
For a fast decision about a Medicare Part D drug that you have not yet received.
We will give you our decision within 72 hours after receiving the appeal request. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2.
Next steps if the plan says "no"
If you asked for Medicare Part D drugs or payment for Medicare Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the Independent Review Entity (Appeal Level 2).
If you choose to appeal, you must send the appeal request to the Independent Review Entity (IRE). The decision you receive from the plan (Appeal Level 1) will tell you how to file the appeal, including who can file the appeal and how soon it must be filed. You must file your appeal within 60 days from the date on the letter you receive.
To obtain an aggregate number of the plan's grievances, appeals and exceptions please contact UnitedHealthcare.
The following information about your Medicare Part D Drug Benefit is available upon request:
Quality assurance policies and procedures
The Utilization Management/Quality Assurance (UM/QA) program is designed to help ensure safe and appropriate use of prescription drugs covered under Medicare Part D. This program focuses on reducing adverse drug events and drug interactions, optimizing medication utilization, and providing incentives to reduce costs when medically appropriate. UnitedHealthcare offers the UM/QA program at no additional cost to its members and their providers.
Utilization management
The UM/QA program incorporates utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits and step therapy.
Quality assurance
As part of the UM/QA program, all prescriptions are screened by drug utilization review systems developed to detect and address the following clinical issues:
The UM/QA program helps ensure that a review of prescribed therapy is performed before each prescription is dispensed. These concurrent drug reviews are implemented as clinical edits at the point-of-sale or point-of-distribution.
In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.
Who can file a Grievance?
A grievance may be filed by any of the following:
What is a Grievance?
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 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.
When can a Grievance be filed?
Complaints related to Part D must be made within 90 calendar days after you had the problem you want to complain about. Complaints regarding any other Medicare or Medicaid Issue must be made within 90 calendar days after you had the problem you want to complain about. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. Complaints about access to care are answered in 2 business days.
Expedited Grievance
You have the right to request an expedited grievance if you disagree with your health plan's decision to invoke an extension on your request for an organization determination or reconsideration, or your health plan's decision to process your expedited reconsideration request as a standard request. In such cases, health plan will respond to your grievance within twenty-four (24) hours of receipt.
Where can a Grievance be filed?
Call Member Services at 1-877-542-9236 (TTY 711) 8 a.m. – 8 p.m. local time, Monday through Friday (voicemail available 24 hours a day/7 days a week). Or you can write us at:
UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department
P.O. Box 31364
Salt Lake City, UT 84131 0364
Expedited Fax: 801-994-1349
Standard Fax: 801-994-1082
Why file a Grievance?
You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information.
Filing a grievance (making a complaint) about your prescription coverage
A grievance is a complaint other than one that involves a request for a coverage determination. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Grievances do not involve problems related to approving or paying for Medicare Part D drugs.
Some types of problems that might lead to filing a grievance include:
If you have any of these problems and want to make a complaint, it is called "filing a grievance."
Who may file a grievance
You or someone you name may file a grievance. The person you name would be your "representative." You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you.
If you want someone to act for you who is not already authorized by the Court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. To learn how to name your representative, call UnitedHealthcare® Customer Service.
Filing a grievance with our plan
The process for making a complaint is different from the process for coverage decisions and appeals. If you have a complaint, you or your representative may call the phone number for Medicare Part D Grievances (for complaints about Medicare Part D drugs) listed on the back of your member ID card. We will try to resolve your complaint over the phone.
If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us.
Submit a written request for a grievance to Part C & D Grievances:
Write of us at the following address:
UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department:
P.O. Box 31364
Salt Lake City, UT 84131 0364
Expedited Fax: 801-994-1349
Standard Fax: 801-994-1082
If you ask for a written response, file a written grievance, or your complaint is related to quality of care, we will respond in writing.
If you are making a complaint because we denied your request for a "fast coverage decision" or a "fast appeal," we will automatically give you a "fast" complaint. If you have a "fast" complaint, it means we will give you an answer within 24 hours.
Write of us at the following address:
UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department:
P.O. Box 31364
Salt Lake City, UT 84131 0364
Please be sure to include the words "fast", "expedited" or "24-hour review" on your request.
Whether you call or write, you should contact Customer Service right away. Complaints related to Part D must be made within 90 calendar days after you had the problem you want to complain about. Complaints regarding any other Medicare or Medicaid issue must be made within 90 calendar days after you had the problem you want to complain about. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days.
Please refer to your plan's Appeals and Grievance process: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage Document or your plan's member handbook.
Your Medicare Advantage health plan must follow strict rules for how they identify, track, resolve and report all appeals and grievances.
An appeal may be filed by any of the following:
What is an Appeal?
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.
When can an Appeal be filed?
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:
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.
Where can an Appeal be filed?
An appeal may be filed in writing directly to us.
UnitedHealthcare Appeals and Grievances Department Part C
P. O. Box 31364
Salt Lake City, UT 84131-0364
Fax: 1-888-517-7113 : Fax/Expedited appeals only – 1-866-373-1081
OR
Call 1-800-290-4009 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
An appeal may be filed in writing directly to us.
UnitedHealthcare Appeals and Grievances Department Part D
PO Box 6103, MS CA 124-0197
Cypress CA 90630-0023
Fax/Expedited appeals only – 1-866-308-6294
OR
Call 1-800-290-4909 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
Why file an Appeal?
You may use the appeal procedure when you want a reconsideration of a decision (organization determination) that was made regarding a service or the amount of payment your Medicare Advantage health plan paid for a service.
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:
If your Medicare Advantage health plan or your Primary Care Provider 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 plus fourteen (14) calendar days, if an extention is taken, after receiving the request.
Who can file a Grievance?
A grievance may be filed by any of the following:
What is a Grievance?
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.
When can a Grievance be filed?
You may file a verbal by calling customer service or a written grievance by writing to the plan within sixty (60) of the date the circumstance giving rise to the grievance. Note: The sixty (60) day limit may be extended for good cause. Include your written request the reason why you could not file within sixty (60) day timeframe.
Expedited Grievance
You have the right to request an 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 reconsideration request as a standard request. In such cases, your Medicare Advantage health plan will respond to your grievance within twenty-four (24) hours of receipt.
Where can a Grievance be filed?
A grievance may be filed verbally or in writing.
A verbal grievance may be filled by calling the Customer Service number on the back of your ID card. For complaints about Part D Drugs you may also call the phone number for Medicare Part D Grievances listed on the back of your ID Card. If we were unable to resolve your complaint over the phone you may file written complaint.
A written Grievance may be filed by writing to
UnitedHealthcare Appeals and Grievances Department Part C
P. O. Box 31364
Salt Lake City, UT 84131-0364
Fax: 1-888-517-7113 : Fax/Expedited appeals only – 1-866-373-1081
OR
Call 1-800-290-4009 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
An appeal may be filed in writing directly to us.
UnitedHealthcare Appeals and Grievances Department Part D
PO Box 6103, MS CA 124-0197
Cypress CA 90630-0023
Fax/Expedited appeals only – 1-866-308-6294
OR
Call 1-800-290-4009 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
Why file a Grievance?
You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your Medicare Advantage health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information.
Grievance, Coverage Determinations and Appeals
Filing a grievance (making a complaint) about your prescription coverage
A grievance is a complaint other than one that involves a request for a coverage determination. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Grievances do not involve problems related to approving or paying for Medicare Part D drugs.
Some types of problems that might lead to filing a grievance include:
If you have any of these problems and want to make a complaint, it is called "filing a grievance."
You or someone you name may file a grievance. The person you name would be your "representative." You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you.
If you want someone to act for you who is not already authorized by the Court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. To learn how to name your representative, call UnitedHealthcare® Customer Service.
The process for making a complaint is different from the process for coverage decisions and appeals. If you have a complaint, you or your representative may call the phone number for Medicare Part D Grievances (for complaints about Medicare Part D drugs) listed on the back of your member ID card. We will try to resolve your complaint over the phone.
If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us.
Submit a written request for a Part D related grievance to:
UnitedHealthcare Community Plan
Appeals & Grievance Dept.
PO Box 6106, M/S CA 124-0197
Cypress,CA 90630-0016
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
If you ask for a written response, file a written grievance, or if your complaint is related to quality of care, we will respond in writing.
If you are making a complaint because we denied your request for a "fast coverage decision" or a "fast appeal," we will automatically give you a "fast" complaint. If you have a "fast" complaint, it means we will give you an answer within 24 hours.
Please be sure to include the words "fast", "expedited" or "24-hour review" on your request.
Whether you call or write, you should contact Customer Service right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days.
If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint.
Review the Evidence of Coverage for additional details.
Coverage Determinations
An initial coverage decision about your Part D drugs is called a “coverage decision.” A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.
In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under your plan, that isn't a coverage determination. You need to call or write to us to ask for a formal decision about the 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. Some covered drugs may have additional requirements or limits that help ensure safe, effective and affordable drug use If there is a restriction for your drug, it usually means that you (or your doctor) will have to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you.
You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names in the plan's drug list. To find the plan's drug list go to View plans and pricing and enter your ZIP code. Choose one of the available plans in your area and view the plan details. You’ll find the form you need in the Helpful Resources section.
Some drugs covered by the Medicare Part D plan have "limited access" at network pharmacies because:
Requirements and limits apply to retail and mail service. These may include:
Prior Authorization (PA)
The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.
Quantity Limits (QL)
The plan will cover only a certain amount of this drug , or a cumulative amount across a category of drugs (such as opioids), for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.
Step Therapy (ST)
There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Medicare Part B or Medicare Part D Coverage Determination (B/D)
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.
NOTE: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.
IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN'S COVERAGE RULES
You can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.
Formulary Exceptions
Cost Sharing Exceptions
Generally, the plan will only approve your request for an exception if the alternative drugs included in the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.
Call the UnitedHealthcare Customer Service number to request a coverage determination (coverage decision). When requesting a formulary or tiering exception or asking for the plan to cover an additional amount of a drug with a quantity limit or asking for the plan to waive a step therapy requirement, a statement from your doctor supporting your request is required. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor's supporting statement (if required).
You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.
If you are a continuing member in the plan, you may notice that a formulary medication which you are currently taking is either not on the 2020 formulary or its cost-sharing or coverage is limited in the upcoming year.
If you are affected by a change in drug coverage you can:
In some situations, we will cover a one-time, temporary supply. During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. To initiate a coverage determination request, please contact UnitedHealthcare.
Have the following information ready when you call:
You may also request a coverage decision/exception by logging on to www.optumrx.com and submitting a request. If you are a new user with www.optumrx.com, you will need to register before you can access the Prior Authorization request tool. Once you have registered, you will find the Prior Authorization tool under the Health Tools Menu. Once your request has been submitted, we will attempt to contact your prescriber to get a supporting statement and/or additional clinical information needed to make a decision.
Download this form to request an exception:
To have your doctor make a request
Your doctor or provider can contact UnitedHealthcare at 1-800-711-4555 for the Prior Authorization department to submit a request, or fax toll-free to 1-844-403-1028. The plan's decision on your exception request will be provided to you by telephone or mail. In addition, the initiator of the request will be notified by telephone or fax.
Your doctor can also request a coverage decision by going to www.professionals.optumrx.com.
To inquire about the status of a coverage decision, contact UnitedHealthcare.
Please refer to your plan’s Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage document or your plan’s member handbook.
Note: Existing plan members who have already completed the coverage determination process for their medications in 2020 may not be required to complete this process again.
What happens if we deny your request?
If we deny your request, we will send you a written reply explaining the reasons for denial. If an initial decision does not give you all that you requested, you have the right to appeal the decision. See How to appeal a decision about your prescription coverage.
How to appoint a representative to help you with a coverage determination or an appeal.
The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case. Click here to find and download the CMS Appointment of Representation form.
Both you and the person you have named as an authorized representative must sign the representative form.
For Coverage Determinations
OptumRX Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Fax: 1-844-403-1028
For Appeals
Medicare Part D Appeals and Grievance Department
PO Box 6103, M/S CA 124-0197
Cypress, CA 90630-9948
Fax: 1-866-308-6294
If your prescribing doctor calls on your behalf, no representative form is required.
If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.
How to appeal a decision about your prescription coverage
Appeal Level 1 - You may ask us to review an adverse coverage decision we’ve issued to you, even if only part of our decision is not what you requested. An appeal to the plan about a Medicare Part D drug is also called a plan "redetermination."
Appeal Level 2 – If we reviewed your appeal at "Appeal Level 1" and did not decide in your favor, you have the right to appeal to the Independent Review Entity (IRE).
When we receive your request to review the adverse coverage determination, we give the request to people at our organization not involved in making the initial determination. This helps ensure that we give your request a fresh look.
To file an appeal:
The information on how to file a Level 1 Appeal can also be found in the adverse coverage decision letter.
To inquire about the status of an appeal, contact UnitedHealthcare.
Submit a written request for a Part C and Part D grievance to:
UnitedHealthcare Coverage Determination Part C
P. O. Box 5250
Kingston, NY 12402-5250
Fax/Expedited 1-501-262-7072
OR
Call: 1-800-290-4009 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
An appeal may be filed in writing directly to us.
UnitedHealthcare Coverage Determination Part D
P. O. Box 5250
Kingston, NY 12402-5250
Fax: Fax/Expedited Fax – 1-501-262-7072 OR
Call: 1-800-290-4009 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
Who may file your appeal of the coverage determination?
If you are appealing a coverage decision about a Medicare Part D drug, you, your authorized representative, or a prescriber (or his and her office staff) may file a standard appeal request or a fast appeal request.
How soon must you file your appeal?
You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.
How soon will we decide on your appeal?
For a standard decision regarding reimbursement for a Medicare Part D drug you have paid for and received and for standard appeal review requests for drugs you have not yet received:
We will give you our decision within 7 calendar days of receiving the pre-service appeal request and 14 days for a reimbursement request. If we do not give you our decision within 7/14 calendar days, your request will automatically go to Appeal Level 2 (Independent Review Entity).
For a fast decision about a Medicare Part D drug that you have not yet received.
We will give you our decision within 72 hours after receiving the appeal request. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2.
Next steps if the plan says "no"
If you asked for Medicare Part D drugs or payment for Medicare Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the Independent Review Entity (Appeal Level 2).
If you choose to appeal, you must send the appeal request to the Independent Review Entity (IRE). The decision you receive from the plan (Appeal Level 1) will tell you how to file the appeal, including who can file the appeal and how soon it must be filed. You must file your appeal within 60 days from the date on the letter you receive.
To obtain an aggregate number of the plan's grievances, appeals and exceptions please contact UnitedHealthcare.
The following information about your Medicare Part D Drug Benefit is available upon request:
Quality assurance policies and procedures
The Utilization Management/Quality Assurance (UM/QA) program is designed to help ensure safe and appropriate use of prescription drugs covered under Medicare Part D. This program focuses on reducing adverse drug events and drug interactions, optimizing medication utilization, and providing incentives to reduce costs when medically appropriate. UnitedHealthcare offers the UM/QA program at no additional cost to its members and their providers.
Utilization management
The UM/QA program incorporates utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits and step therapy.
Quality assurance
As part of the UM/QA program, all prescriptions are screened by drug utilization review systems developed to detect and address the following clinical issues:
The UM/QA program helps ensure that a review of prescribed therapy is performed before each prescription is dispensed. These concurrent drug reviews are implemented as clinical edits at the point-of-sale or point-of-distribution.
In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.
Your health plan must follow strict rules for how they identify, track, resolve and report all appeals and grievances.
Medicare Part D Prior Authorization, Formulary Exception or Coverage Determination Request(s)
Medicare Part D prior authorization forms list
Prescription Drugs - Not Covered by Medicare Part D
While most of your prescription drugs will be covered by Medicare Part D, there are a few drugs that are not covered by Medicare Part D but are covered by UnitedHealthcare® Connected™. You can view our plan's List of Covered Drugs on our website at www.myuhc.com/communityplan. Drugs with an asterisk are not covered by Medicare Part D but are covered by UnitedHealthcare® Connected™ (Medicare-Medicaid Plan). You do not have any co-pays for non-Part D drugs covered by our plan.
Please note that our list of medications that require prior authorization, formulary exceptions or coverage determinations can change
Submit a Pharmacy Prior Authorization. Formulary Exception or Coverage Determination Request to OptumRx.
Submit a Pharmacy Prior Authorization Request, Forumulary Exception or Coverage Determination electronically to OptumRx.
Who can file an Appeal?
An appeal may be filed by any of the following:
What is an Appeal?
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 health plan pays or will pay for a service or the amount you must pay for a service.
When can an Appeal be filed?
You may file an appeal within ninety (90) calendar days of the date of the notice of the initial coverage decision. For example, you may file an appeal for any of the following reasons:
Note: The ninety (90) day limit may be extended for good cause. Include in your written request the reason why you could not file within the ninety (90) day timeframe.
If you are appealing because you were told that a service you are getting will be reduced or stopped, you have a shorter timeframe to appeal if you want us to continue covering that service while the appeal is processing. For more information, please see your Member Handbook.
In most cases, you must file your appeal with the Health Plan. However, if your problem is about a service or item covered primarily by Medicaid or both Medicare and Medicaid, you can request a State Hearing which is filed with the Bureau of State Hearings.
To file a State Hearing, your request must be made within 90 calendar days of receiving the notice of your State Hearing rights. The 90 calendar days begins on the day after the mailing date on the notice. If you have a good reason for being late the Bureau of State Hearings may extend this deadline for you.
For more information regarding State Hearings, please see your Member Handbook.
Where can an Appeal be filed?
An appeal may be filed by calling us at 1-800-256-6533 (TTY 711) 8 a.m. to 8p.m. local time, Monday through Friday (voicemail available 24 hours a day/7 days a week) writing directly to us, calling us or submitting a form electronically.
How do I Start an Appeal?
To start your appeal, you, your doctor or other provider, or your representative must contact us. You can call us at 1-800-256-6533 (TTY 7-1-1), 8 a.m. – 8 p.m. local time, Monday – Friday.
You can submit a request to the following address:
Part D Appeals:
UnitedHealthcare Community Plan
Attn: Part D Standard Appeals
P.O. Box 6103
Cypress, CA 90630-9948
Standard Fax: 877-960-8235
Part C Appeals:
Write of us at the following address:
UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department:
P.O. Box 31364
Salt Lake City, UT 84131 0364
Expedited Fax: 801-994-1349
Standard Fax: 801-994-1082
Why file an Appeal?
You may use the appeal procedure when you want a reconsideration of a decision (organization determination) that was made regarding a service or the amount of payment your health plan paid for a service
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:
If your Medicare Advantage health plan or your Primary Care Provider 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 plus fourteen (14) calendar days, if an extention is taken, after receiving the request.
Coverage Determination
Asking for a coverage determination (coverage decision)
The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for prescription drugs, including problems related to payment. This is the process you use for issues such as whether a drug is covered or not and the way in which the drug is covered.
An initial coverage decision about your Part D drugs is called a "coverage determination.", or simply put, a "coverage decision." A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.
Drug requirements and limitations
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. Some covered drugs may have additional requirements or limits that help ensure safe, effective and affordable drug use. And some drugs may require a coverage determination to verify whether they are covered by the Medicare Part D plan. The coverage determination process allows you or your prescriber to request coverage of drugs with additional requirements or ask for exceptions to your benefits.
You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names in the plan's drug list. To find the plan's drug list go to the ‘Find a Drug' Look Up Page and download your plan's formulary.
Some drugs covered by the Medicare Part D plan have "limited access" at network pharmacies because:
Requirements and limits apply to retail and mail service. These may include:
Prior Authorization (PA)
The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.
Quantity Limits (QL)
The plan will cover only a certain amount of this drug for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.
Step Therapy (ST)
There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Medicare Part B or Medicare Part D Coverage Determination (B/D)
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.
NOTE: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.
IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN'S COVERAGE RULES
You can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.
Formulary Exceptions
Cost Sharing Exceptions
Generally, the plan will only approve your request for an exception if the alternative drugs included in the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.
How to request a coverage determination (including benefit exceptions)
Call the UnitedHealthcare Customer Service number to request a coverage determination (coverage decision). When requesting a formulary or tiering exception or asking for the plan to cover an additional amount of a drug with a quantity limit or asking for the plan to waive a step therapy requirement, a statement from your doctor supporting your request is required. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor's supporting statement (if required).
You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.
If you are a continuing member in the plan, you may notice that a formulary medication which you are currently taking is either not on the 2020 formulary or its cost-sharing or coverage is limited in the upcoming year.
If you are affected by a change in drug coverage you can:
In some situations, we will cover a one-time, temporary supply. During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. To initiate a coverage determination request, please contact UnitedHealthcare.
Have the following information ready when you call:
You may also request a coverage decision/exception by logging on to www.optumrx.com and submitting a request. If you are a new user with www.optumrx.com, you will need to register before you can access the Prior Authorization request tool. Once you have registered, you will find the Prior Authorization tool under the Health Tools Menu. Once your request has been submitted, we will attempt to contact your prescriber to get a supporting statement and/or additional clinical information needed to make a decision.
Download this form to request an exception:
To have your doctor make a request
Your doctor or provider can contact UnitedHealthcare at 1-800-711-4555 for the Prior Authorization department to submit a request, or fax toll-free to 1-844-403-1028. The plan's decision on your exception request will be provided to you by telephone or mail. In addition, the initiator of the request will be notified by telephone or fax.
Your doctor can also request a coverage decision by going to www.professionals.optumrx.com.
To inquire about the status of a coverage decision, contact UnitedHealthcare.
Please refer to your plan’s Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage document or your plan’s member handbook.
Note: Existing plan members who have already completed the coverage determination process for their medications in 2020 may not be required to complete this process again.
What happens if we deny your request?
If we deny your request, we will send you a written reply explaining the reasons for denial. If an initial decision does not give you all that you requested, you have the right to appeal the decision. See How to appeal a decision about your prescription coverage.
How to appoint a representative to help you with a coverage determination or an appeal.
The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case. Click here to find and download the CMS Appointment of Representation form.
Both you and the person you have named as an authorized representative must sign the representative form.
For Coverage Determinations
OptumRX Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Fax: 1-844-403-1028
For Appeals
Medicare Part D Appeals and Grievance Department
PO Box 6103, M/S CA 124-0197
Cypress, CA 90630-9948
Fax: 1-866-308-6294
If your prescribing doctor calls on your behalf, no representative form is required.d.
Making an appeal
If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.
How to appeal a decision about your prescription coverage
Appeal Level 1 - You may ask us to review an adverse coverage decision we've issued to you, even if only part of our decision is not what you requested. An appeal to the plan about a Medicare Part D drug is also called a plan "redetermination."
Appeal Level 2 – If we reviewed your appeal at "Appeal Level 1" and did not decide in your favor, you have the right to appeal to the Independent Review Entity (IRE).
When we receive your request to review the adverse coverage determination, we give the request to people at our organization not involved in making the initial determination. This helps ensure that we give your request a fresh look.
To file an appeal:
Part D Appeals:
UnitedHealthcare Community Plan
Attn: Part D Standard Appeals
P.O. Box 6103
Cypress, CA 90630-9948
Standard Fax: 877-960-8235
Part C Appeals:
Write of us at the following address:
UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department:
P.O. Box 31364
Salt Lake City, UT 84131 0364
Expedited Fax: 801-994-1349
Standard Fax: 801-994-1082
You must mail your letter within 60 days of the date the adverse determination was issues, or within 60 days from the date of the denial of reimbursement request. If you missed the 60-day deadline, you may still file your appeal if you provide a valid reason for missing the deadline.
To inquire about the status of an appeal, contact UnitedHealthcare.
Who may file your appeal of the coverage determination?
If you are appealing a coverage decision about a Medicare Part D drug, you, your authorized representative, or a prescriber (or his and her office staff) may file a standard appeal request or a fast appeal request.
How soon must you file your appeal?
You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.
How soon will we decide on your appeal?
For a standard decision regarding reimbursement for a Medicare Part D drug you have paid for and received and for standard appeal review requests for drugs you have not yet received:
We will give you our decision within 7 calendar days of receiving the appeal request. If we do not give you our decision within 7 calendar days, your request will automatically go to Appeal Level 2 (Independent Review Entity).
For a fast decision about a Medicare Part D drug that you have not yet received.
We will give you our decision within 72 hours after receiving the appeal request. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2.
Next steps if the plan says "no"
If you asked for Medicare Part D drugs or payment for Medicare Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the Independent Review Entity (Appeal Level 2).
If you choose to appeal, you must send the appeal request to the Independent Review Entity (IRE). The decision you receive from the plan (Appeal Level 1) will tell you how to file the appeal, including who can file the appeal and how soon it must be filed. You must file your appeal within 60 days from the date on the letter you receive.
To obtain an aggregate number of the plan's grievances, appeals and exceptions please contact UnitedHealthcare.
The following information about your Medicare Part D Drug Benefit is available upon request:
Quality assurance policies and procedures
The Utilization Management/Quality Assurance (UM/QA) program is designed to help ensure safe and appropriate use of prescription drugs covered under Medicare Part D. This program focuses on reducing adverse drug events and drug interactions, optimizing medication utilization, and providing incentives to reduce costs when medically appropriate. UnitedHealthcare offers the UM/QA program at no additional cost to its members and their providers.
Utilization management
The UM/QA program incorporates utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits and step therapy.
Quality assurance
As part of the UM/QA program, all prescriptions are screened by drug utilization review systems developed to detect and address the following clinical issues:
The UM/QA program helps ensure that a review of prescribed therapy is performed before each prescription is dispensed. These concurrent drug reviews are implemented as clinical edits at the point-of-sale or point-of-distribution.
In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.
Who can file a Grievance?
A grievance may be filed by any of the following:
What is a Grievance?
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 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.
When can a Grievance be filed?
Complaints related to Part D must be made within 90 calendar days after you had the problem you want to complain about. Complaints regarding any other Medicare or Medicaid Issue must be made within 90 calendar days after you had the problem you want to complain about. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. Complaints about access to care are answered in 2 business days.
Expedited Grievance
You have the right to request an expedited grievance if you disagree with your health plan's decision to invoke an extension on your request for an organization determination or reconsideration, or your health plan's decision to process your expedited reconsideration request as a standard request. In such cases, health plan will respond to your grievance within twenty-four (24) hours of receipt.
Where can a Grievance be filed?
Call Member Services at 1-800-256-6533 (TTY 711) 8 a.m. – 8 p.m. local time, Monday through Friday (voicemail available 24 hours a day/7 days a week).
Why file a Grievance?
You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information
Grievance, Coverage Determinations and Appeals
Filing a grievance (making a complaint) about your prescription coverage
A grievance is a complaint other than one that involves a request for a coverage determination. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Grievances do not involve problems related to approving or paying for Medicare Part D drugs.
Some types of problems that might lead to filing a grievance include:
If you have any of these problems and want to make a complaint, it is called "filing a grievance."
Who may file a grievance
You or someone you name may file a grievance. The person you name would be your "representative." You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you.
If you want someone to act for you who is not already authorized by the Court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. To learn how to name your representative, call UnitedHealthcare® Customer Service.
Filing a grievance with our plan
The process for making a complaint is different from the process for coverage decisions and appeals. If you have a complaint, you or your representative may call the phone number for Medicare Part D Grievances (for complaints about Medicare Part D drugs) listed on the back of your member ID card. We will try to resolve your complaint over the phone.
If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us.
Submit a written request for a grievance to Part C & D Grievances:
UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department
P.O. Box 31364
Salt Lake City, UT 84131-0364
Or
Expedited Fax: 801-994-1349
Standard Fax: 801-994-1082.
If you ask for a written response, file a written grievance, or your complaint is related to quality of care, we will respond in writing.
If you are making a complaint because we denied your request for a "fast coverage decision" or a "fast appeal," we will automatically give you a "fast" complaint. If you have a "fast" complaint, it means we will give you an answer within 24 hours.
Please be sure to include the words "fast", "expedited" or "24-hour review" on your request.
Whether you call or write, you should contact Customer Service right away. Complaints related to Part D must be made within 90 calendar days after you had the problem you want to complain about. Complaints regarding any other Medicare or Medicaid issue must be made within 90 calendar days after you had the problem you want to complain about. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days.
If your health plan is not listed above, please refer to our UnitedHealthcare Dual Complete® General Appeals & Grievance Process below.
UnitedHealthcare Dual Complete® General Appeals & Grievance Process
Your Medicare Advantage health plan must follow strict rules for how they identify, track,
Medicare Part D Prior Authorization Forms List
While most of your prescription drugs will be covered by Medicare Part D, there are a few drugs that are not covered by Medicare Part D but are covered by UnitedHealthcare Community Plans. You can view our plan's List of Covered Drugs on our website. Drugs with an asterisk are not covered by Medicare Part D but are covered by UnitedHealthcare Community Plans. You do not have any co-pays for non-Part D drugs covered by our plan.
Please note that our list of medications that require prior authorization, formulary exceptions or coverage determinations can change so it is important for you and/or your provider to check this information when you need to fill/refill a medication.
Submit a Pharmacy Prior Authorization. Forumulary Exception or Coverage Determination Request to OptumRx
Submit a Pharmacy Prior Authorization Request, Forumulary Exception or Coverage Determination electronically to OptumRx.
Appeals
Who can file an Appeal?
An appeal may be filed by any of the following:
What is an Appeal?
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.
When can an Appeal be filed?
You may file an appeal within sixty (60) calendar days of the date of the notice of the initial coverage decision. For example, you may file an appeal for any of the following reasons:
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.
Where can an Appeal be filed?
An appeal may be filed in writing directly to us, calling us or submitting a form electronically.
How do I start an Appeal?
To start your appeal, you, your doctor or other provider, or your representative must contact us.
You can call us at 1-866-842-4968 (TTY 7-1-1), 8 a.m. – 8 p.m. local time, 7 days a week.
Customer Service also has free language interpreter services available for non-English speakers.
You can submit a Part C request to the following address:
UnitedHealthcare Community Plan
Attn: Part D Standard Complaint and Appeals Department
P.O. Box 6106 MS CA 124-0157
Cypress, CA 90630-0016
Fax: 1-888-517-7113 Expedited Fax: 1-866-373-1081
8 a.m. – 8 p.m. local time, 7 days a week.
For an Expedited Part C Appeal: You, your prescriber, or your representative should contact us by telephone 1-877-262-9203 TTY 711, or expedited fax at Expedited Fax: 1-866-373-1081, TTY 711, 8 a.m. – 8 p.m. local time, 7 days a week. Monday through Friday.
You can submit a Part D request to the following address:
UnitedHealthcare Community Plan
Attn: Part D Standard Complaint and Appeals Department
P.O. Box 6106 Cypress, CA 90630-9948
Fax: 1-866-308-6294 Expedited Fax: 1-866-308-6296
Or you can call us at: 1-888-867-5511TTY 711.
Available 8 a.m. - 8 p.m. local time, 7 days a week
Why file an Appeal?
You may use the appeal procedure when you want a reconsideration of a decision (organization determination) that was made regarding a service or the amount of payment your Medicare Advantage health plan paid for a service.
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:
If your Medicare Advantage health plan or your Primary Care Provider 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 plus (14) calendar days, if an extension is taken, after receiving the request.
Asking for a coverage determination (coverage decision)
The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for prescription drugs, including problems related to payment. This is the process you use for issues such as whether a drug is covered or not and the way in which the drug is covered.
An initial coverage decision about your Part D drugs is called a "coverage determination.", or simply put, a "coverage decision." A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.
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. Some covered drugs may have additional requirements or limits that help ensure safe, effective and affordable drug use. And some drugs may require a coverage determination to verify whether they are covered by the Medicare Part D plan. The coverage determination process allows you or your prescriber to request coverage of drugs with additional requirements or ask for exceptions to your benefits.
You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names in the plan's drug list. To find the plan's drug list go to "Find a Drug" and download your plan's Formulary.
Some drugs covered by the Medicare Part D plan have "limited access" at network pharmacies because:
Requirements and limits apply to retail and mail service. These may include:
Prior Authorization (PA)
The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.
Quantity Limits (QL)
The plan will cover only a certain amount of this drug for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.
Step Therapy (ST)
There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Medicare Part B or Medicare Part D Coverage Determination (B/D)
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.
Note: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.
IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN'S COVERAGE RULES
You can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.
Formulary Exceptions
Cost Sharing Exceptions
Generally, the plan will only approve your request for an exception if the alternative drugs included in the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.
Call the UnitedHealthcare Customer Service number to request a coverage determination (coverage decision). When requesting a formulary or tiering exception or asking for the plan to cover an additional amount of a drug with a quantity limit or asking for the plan to waive a step therapy requirement, a statement from your doctor supporting your request is required. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor's supporting statement (if required).
You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.
If you are a continuing member in the plan, you may notice that a formulary medication which you are currently taking is either not on the 2020 formulary or its cost-sharing or coverage is limited in the upcoming year.
If you are affected by a change in drug coverage you can:
In some situations, we will cover a one-time, temporary supply. During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. To initiate a coverage determination request, please contact UnitedHealthcare.
Have the following information ready when you call:
Coverage Decisions for Medical Care Part C – Contact Information:
Write: UnitedHealthcare Customer Service Department (Organization Determinations)
P.O. Box 29675
Hot Springs, AR 71903-9675
Call: 1-866-842-4968 TTY: 711
Calls to this number are free.
Hours of Operation: 8 a.m. - 8 p.m. local time, 7 days a week
Fax: 1-501-262-7072
Coverage Decisions for Part D Prescription Drugs – Contact Information:
Write: UnitedHealthcare Part D Coverage Determinations Department
P.O. Box 31350
Salt Lake City, UT 84131-0365
Call: 1-866-842-4968 TTY: 711
Calls to this number are free.
Hours of Operation: 8 a.m. - 8 p.m. local time, 7 days a week
Fax: 1-800-527-0531
You may also request a coverage decision/exception by logging on to www.optumrx.com and submitting a request. If you are a new user with www.optumrx.com, you will need to register before you can access the Prior Authorization request tool. Once you have registered, you will find the Prior Authorization tool under the Health Tools Menu. Once your request has been submitted, we will attempt to contact your prescriber to get a supporting statement and/or additional clinical information needed to make a decision.
Download this form to request an exception:
To have your doctor make a request
Your doctor or provider can contact UnitedHealthcare at 1-800-711-4555 for the Prior Authorization department to submit a request, or fax toll-free to1-844-403-1028 call at 1-866-842-4968 (TTY 711), 8 a.m. –8 p.m. local time, 7 days a week. The plan's decision on your exception request will be provided to you by telephone or mail. In addition, the initiator of the request will be notified by telephone or fax.
Your doctor can also request a coverage decision by going to www.professionals.optumrx.com.
To inquire about the status of a coverage decision, contact UnitedHealthcare.
Please refer to your plan’s Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage document or your plan’s member handbook.
Note: Existing plan members who have already completed the coverage determination process for their medications in 2020 may not be required to complete this process again.
What happens if we deny your request?
If we deny your request, we will send you a written reply explaining the reasons for denial. If an initial decision does not give you all that you requested, you have the right to appeal the decision. See How to appeal a decision about your prescription coverage.
How to appoint a representative to help you with a coverage determination or an appeal.
The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case. Click here to find and download the CMS Appointment of Representation form.
Both you and the person you have named as an authorized representative must sign the representative form.
For Coverage Determinations
Mail: OptumRx Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Fax: 1-844-403-1028
For Appeals
Mail: Medicare Part D Appeals and Grievance Department
PO Box 6103, M/S CA 124-0197
Cypress, CA 90630-9948
Fax: 1-866-308-6294
If your prescribing doctor calls on your behalf, no representative form is required. Or you can call us at: 1-888-867-5511 TTY 711. Available 8 a.m. - 8 p.m. local time, 7 days a week.
If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.
How to appeal a decision about your prescription coverage
Appeal Level 1 - You may ask us to review an adverse coverage decision we've issued to you, even if only part of our decision is not what you requested. An appeal to the plan about a Medicare Part D drug is also called a plan "redetermination."
Appeal Level 2 – If we reviewed your appeal at "Appeal Level 1" and did not decide in your favor, you have the right to appeal to the Independent Review Entity (IRE).
When we receive your request to review the adverse coverage determination, we give the request to people at our organization not involved in making the initial determination. This helps ensure that we give your request a fresh look.
To file an appeal:
P.O. Box 6106
M/S CA 124-0197
Cypress CA 90630-9948
To inquire about the status of an appeal, contact UnitedHealthcare.
Who may file your appeal of the coverage determination?
If you are appealing a coverage decision about a Medicare Part D drug, you, your authorized representative, or a prescriber (or his and her office staff) may file a standard appeal request or a fast appeal request.
How soon must you file your appeal?
You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.
How soon will we decide on your appeal?
For a standard decision regarding reimbursement for a Medicare Part D drug you have paid for and received and for standard appeal review requests for drugs you have not yet received:
We will give you our decision within 7 calendar days of receiving the appeal request. If we do not give you our decision within 7 calendar days, your request will automatically go to Appeal Level 2 (Independent Review Entity).
For a fast decision about a Medicare Part D drug that you have not yet received.
We will give you our decision within 72 hours after receiving the appeal request. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2.
Next steps if the plan says "no"
If you asked for Medicare Part D drugs or payment for Medicare Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the Independent Review Entity (Appeal Level 2).
If you choose to appeal, you must send the appeal request to the Independent Review Entity (IRE). The decision you receive from the plan (Appeal Level 1) will tell you how to file the appeal, including who can file the appeal and how soon it must be filed. You must file your appeal within 60 days from the date on the letter you receive.
To obtain an aggregate number of the plan's grievances, appeals and exceptions please contact UnitedHealthcare.
The following information about your Medicare Part D Drug Benefit is available upon request:
Quality assurance policies and procedures
The Utilization Management/Quality Assurance (UM/QA) program is designed to help ensure safe and appropriate use of prescription drugs covered under Medicare Part D. This program focuses on reducing adverse drug events and drug interactions, optimizing medication utilization, and providing incentives to reduce costs when medically appropriate. UnitedHealthcare offers the UM/QA program at no additional cost to its members and their providers.
Utilization management
The UM/QA program incorporates utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits and step therapy.
Quality assurance
As part of the UM/QA program, all prescriptions are screened by drug utilization review systems developed to detect and address the following clinical issues:
In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.
Who can file a Grievance?
A grievance may be filed by any of the following:
What is a Grievance?
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.
When can a Grievance be filed?
You may file a grievance within sixty (60) calendar days of the date of the circumstance giving rise to the grievance.
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.
Expedited Grievance
You have the right to request an 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 reconsideration request as a standard request. In such cases, your Medicare Advantage health plan will respond to your grievance within twenty-four (24) hours of receipt.
Where can a Grievance be filed?
A grievance may be filed in writing directly to us.
Why file a Grievance?
You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your Medicare Advantage health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information.
Grievance, Coverage Determinations and Appeals
Filing a grievance (making a complaint) about your prescription coverage
A grievance is a complaint other than one that involves a request for a coverage determination. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Grievances do not involve problems related to approving or paying for Medicare Part D drugs.
Some types of problems that might lead to filing a grievance include:
Who may file a grievance
You or someone you name may file a grievance. The person you name would be your "representative." You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you.
If you want someone to act for you who is not already authorized by the Court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. To learn how to name your representative, call UnitedHealthcare® Customer Service.
Filing a grievance with our plan
The process for making a complaint is different from the process for coverage decisions and appeals. If you have a complaint, you or your representative may call the phone number for Grievances listed on the back of your member ID card. We will try to resolve your complaint over the phone.
You can call us at 1-866-842-4968 (TTY 7-1-1), 8 a.m. – 8 p.m. local time, 7 days a week.
Customer Service also has free language interpreter services available for non-English speakers.
If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us.
Submit a written request for a grievance to Part C & D Grievances:
UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department
P.O. Box 6106,
Cypress CA 90630-9948
Or
Expedited Fax: 1-866-308-6296
Standard Fax: 1-866-308-6294
If you ask for a written response, file a written grievance, or if your complaint is related to quality of care, we will respond in writing.
If you are making a complaint because we denied your request for "fast coverage decision" or a "fast appeal," we will automatically give you a "fast" complaint. If you have a "fast" complaint, it means we will give you an answer within 24 hours.
1. You may submit a written request for a Fast Grievance to the Medicare Part D Appeals & Grievance Dept. at:
P.O. Box 6106
Cypress, CA 90630-9948
2. You may fax your written request toll-free to 1-866-308-6296; or
3. You may contact UnitedHealthcare to file an expedited Grievance. Please be sure to include the words "fast," "expedited" or "24-hour review" on your request.
Whether you call or write, you should contact Customer Service right away. The complaint must be made within 60 calendar days, after you had the problem you want to complain about. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days.
If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. If we do not agree with some or all of your complaint or don't take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.
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