Medicare Advantage

Part D Authorizations, Exceptions, Appeals and Grievances

(2014)

Your plan has a "formulary" that lists drugs that are covered, and most can be obtained by simply presenting your prescription at a participating pharmacy and paying your part of the cost. A few other drugs need to be authorized in advance for medical necessity, and some drugs are not covered at all. Your formulary generally has at least two drugs in each category, so you should almost always be able to find an alternative that works for you.

This page provides answers to frequently asked questions about procedures for obtaining drugs or filing complaints about your benefits, and we hope you find it useful. Please contact us if you need any additional assistance.

Covered drugs and prior authorizations

Q1: How do I know what drugs are covered, and which ones require authorization?
A1: Your formulary will list the drugs that are covered and indicate which drugs require prior authorization.

 Florida Hospital SunSaver (HMO) and Florida Hospital Explorer (HMO-POS) comprehensive formulary  — a complete list of covered drugs

Q2: How do I get prior authorization for a drug?
A2: Your doctor will typically send us a request, including any clinical information to support it, or you can use the form below. Simply complete the form and submit it to us according to the instructions.

PDF Medicare Prescription Drug Exception & Appeal Form 

Q3: How do I know what drugs are not covered on the formulary?
A3: If a drug is not listed on the comprehensive formulary, then it is not covered. Additionally, the following drugs are specifically excluded by the Medicare Part D program, so Health First Health Plans does not cover them:

  1. Drugs used for anorexia, weight loss, or weight gain

  2. Drugs used to promote fertility

  3. Drugs used for cosmetic purposes or hair growth

  4. Drugs used for the symptomatic relief of cough and colds

  5. Prescription vitamins & mineral products, except prenatal vitamins & fluoride preparations

  6. Non-prescription drugs

  7. Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee

  8. Drugs used for treatment of sexual or erectile dysfunction, unless such agents are used to treat a condition, other than sexual or erectile dysfunction, for which the agents have been approved by the Food and Drug Administration

Exceptions

Q4: What do I do if my drug isn't on the formulary?
A4: Try to find a covered formulary alternative in the same therapeutic class. If this is not an option and the drug is not excluded under Medicare Part D, you can request an exception as described in A6. (Exceptions are not granted for excluded Part D drugs; See A3  for list of excluded drugs.)

Q5: What if a formulary alternative is not effective or causes adverse effects?
A5: If a formulary alternative is not an option and the drug is not excluded under Medicare Part D, you can request an exception as described in A6. (Exceptions are not granted for excluded Part D drugs; See A3  for list of excluded drugs.)

Q6: How do I request a formulary exception?
A6: The best way is to have your doctor fax a completed request form, along with their supporting statement and any clinical documentation, to our Pharmacy Department at (321) 434-4752.

You or your doctor can also submit your request online (by clicking this link you will be leaving Health First Health Plans' web site).

Or you can use the form below. Simply complete the form and submit it to us according to the instructions.

PDF Medicare Prescription Drug Coverage Determination Request Form — for members

PDF Medicare Prescription Drug Coverage Determination Request Form — for providers

Q7: What should be included with the exception request?
A7: A physician's statement indicating why the drug is medically necessary, in addition to clinical documentation supporting the request. To be eligible for an exception, the request must demonstrate that a formulary drug would (1) not be as effective as the drug being requested, (2) would cause adverse effects, or (3) both. When applicable, it should also indicate which other drugs failed or caused adverse effects.

Q8: What if all the required information isn't submitted with the exception request?
A8: If a request is received without all the required documentation, it will be considered "incomplete" and returned to the doctor with a request for information. It will not be reviewed until all the required elements have been submitted, and will be denied if the requested information is not received after 96 hours (4 days).

Q9: If I request an exception with all the required information, will it be approved?
A9: Not necessarily. It will be reviewed by a Medical Director, and a decision will be based on clinical evidence, your unique medical condition, and characteristics of the drug itself.

Q10: How long will it take to get a decision on my exception request?
A10: A decision will be made within 72 hours (3 days) for complete standard requests, and 24 hours (1 day) if the standard timeframe could jeopardize your health. Your doctor should indicate if the fast timeframe is warranted, and the decision will be made in 24 hours. Contact customer service to find out the status of your request.

Q11: How will I know about the plan's decision on my exception request?
A11: If the exception is approved, you and your doctor will receive an approval letter indicating the authorization number and length of coverage. If the request is denied, you and your doctor will receive a denial letter indicating the reason for the decision and how to appeal it if you choose.

Q12: If my exception request is approved, what will my cost-share be?
A12: If a formulary exception is approved, you will be responsible for the highest cost-share for prescription drugs under your plan.

Appeals

Q13: If my exception request is denied, how can I appeal?
A13: If drug coverage is denied, your or your authorized representative can file an appeal by writing to us within 60 days from the denial, telling us why you believe the decision was incorrect. If the situation is urgent and you need a decision quickly, your doctor will automatically be considered your authorized representative and can appeal on your behalf. Expedited appeals will be accepted in writing, or verbally by contacting customer service. If the appeal is not urgent, you can file a written appeal, or authorize your physician to act on your behalf in writing, or call us at (855) 882-6467 weekdays from 8 am to 8 pm and Saturday from 8 am to noon, or though TDD Relay at (800) 955-8771. Appeals will be decided within 7 days unless your medical condition warrants an expedited timeframe, in which the appeal will be decided within 72 hours. You will have the right to an external review if the decision is still not in your favor.

You or your doctor or representative can also submit your request online (by clicking this link you will be leaving Health First Health Plans' web site).

Or you can also use the form below. Simply complete the form and submit it to us according to the instructions.

Q14: If I have been denied coverage for a drug I think should be covered, or don't agree with the amount I was charged, what can I do?
A14: You have the right to appeal as described in A13 .

Grievances

Q15: What can I do if I have a complaint about something other than coverage for a specific drug I requested?
A15: If you are dissatisfied with any aspect of your prescription drug plan, including a decision not to expedite a coverage decision for you, you can file a grievance within 60 days of the incident. We hope that you will call us first about your concern, but if we cannot resolve it for you immediately, you can also send a written grievance along with supporting information to:

Health First Health Plans
Attn: Member Advocate
6450 US Highway 1
Rockledge, FL 32955

To contact us by phone, please call (321) 434-5665 or (800) 716-7737 weekdays from 8 am to 8 pm and Saturday from 8 am to noon. TDD Relay users can also contact us at (800) 955-8771 during the same hours.

Q16: What happens after I file a grievance?
A16: Appropriate people at Health First Health Plans will investigate your concern and advise you of the outcome of the review within 30 days, unless a 14-day extension is warranted. Your satisfaction is our greatest concern and we will do everything possible to ensure you are treated fairly.

Q17: What if my grievance is related to the quality of care I received?
A17: You can file a grievance with Health First Health Plans as described above, and can also file your grievance with the Florida Quality Improvement Organizations (QIO) by contacting them at the following address and telephone number listed below:

Florida Medical Quality Assurance, Inc.
5201 W. Kennedy Boulevard, Suite #900
Tampa, FL 33609

Phone: (813) 354-9111

How to contact Medicare

Our Customer Service Representatives are dedicated to personally solving any problems you may have with us and our providers to your full satisfaction. If you prefer to contact the Centers for Medicare and Medicaid Services (CMS) directly, please visit Medicare's web site:


Y0089_MP3536FH Approved 11/06/2013
Last updated: 01/17/2014