Member and Provider Information and Forms

Coverage Determinations, Exception Requests, and Appeals & Grievances

Coverage Determinations/Exception Requests

For situations in which you have a medication that is not on CCM Direct’s formulary or is part of a tier level designated as non-preferred, but you believe it should be placed in a different tier, an exceptions process has been established by the plan. Exception requests will be reviewed by the Plan for coverage determination.

Your prescribing physician must provide supporting medical information in response to a coverage exception request related to a non-formulary drug or tier placement.

There are two kinds of coverage determination requests - fast and standard. A member can request a fast coverage determination, which will be decided within 24 hours. The request for a fast coverage determination must meet criteria that the standard coverage determination review process time frame would jeopardize the member’s health status. For standard coverage determination requests, notification will occur 72 hours after receipt of the request or written documentation of medical necessity from the physician. Non-formulary drugs approved for coverage will be covered at the non-preferred brand level. Biotech and specialty non-formulary products approved for coverage will be covered at the specialty level. A fast coverage determination or exception request can be made verbally by calling 1-800-935-7195 (TTY/TDD users call: 1-800-855-2881) Monday - Sunday, 8:00 a.m. – 8:00 p.m. To make a coverage determination request or an exception request, see instructions and forms below.

Coverage Determination Form (for submission by Members)
Drug Evaluation Request Form (for submission by Providers)

Information on the aggregate number of CCM Direct’s grievances, appeals, and exceptions is available by contacting CCM Direct Customer Service at 1-800-935-7195 (TTY/TDD users call: 1-800-855-2881) Monday - Sunday, 8:00 a.m. – 8:00 p.m.

Please review the Evidence of Coverage for more detailed information on coverage determination, exception requests and appeals requests.

Appeals (Redetermination and Reconsideration)

A member appeal can be submitted when you want us to reconsider and change a decision we have made about what prescription drug benefits are covered for you or what we will pay for a prescription drug. An appeal must be filed within 60 calendar days of the coverage determination. Two types of appeals are available to members - a fast-track appeal and a standard appeal. Members who submit a fast appeal must meet criteria that the standard process time frame would jeopardize the member’s health status. These fast reviews will be completed within 72 hours. Standard appeal requests will be reviewed within 7 calendar days. Members can make a fast appeal request by calling 1-800-935-7195. To make a request outside of normal business hours, please call 1-800-935-7195. To make a standard appeal request, see instructions and attached forms below.

Member Redetermination form
Member IRE Reconsideration form
Provider Appeal form
Appointment of Representation form

Grievances

A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with CCM Direct or one of our network pharmacies that does not relate to coverage for a prescription drug. If you have a grievance, we encourage you to call Customer Service for a prompt response. We will try to resolve any complaint over the phone. You may also send your complaint in writing. To submit a grievance in writing, please mail to:

Medco Health Solutions, Inc.
PO Box 14711
Lexington, KY 40512

You can also fax a grievance to: 1-718-515-5253. We will notify you of a decision within 30 days of receipt of the written grievance. We may extend this time frame by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. An expedited grievance can be made orally by calling 1-800-935-7195 (TTY/TDD users call: 1-800-855-2881) Monday - Sunday, 8:00 a.m. to 8 p.m.

Member Rights and Responsibilities

As a Medicare beneficiary, you have certain rights that protect you. These rights include:

• Right to be treated with fairness and respect
• Right to privacy of your medical records and personal health information
• Right to get your prescriptions filled within a reasonable period of time
• Right to know your treatment choices and participate in decisions about your health care
• Right to make complaints
• Right to get information about your drug coverage and costs
• Right to get information about CCM Direct and our network pharmacies

If you elect to disenroll from CCM Direct, you also have rights and responsibilities. These include:

• Right to use your CCM Direct prescription drug coverage and our network pharmacies to fill your Rx until your coverage ends.
• If you leave CCM Direct you can join another Medicare PDP or a Medicare Advantage plan as long as this type of plan is available in your area, they are accepting new members, and you meet the eligibility requirements of the plan.

CCM Direct can disenroll a beneficiary in the following circumstances:

• You are no longer eligible for Medicare prescription drug coverage.
• If CCM Direct is no longer contracting with Medicare or leaves your service area.
• When you move out of our service area.
• You materially misrepresent a 3rd party reimbursement.
• You fail to pay premium.
• You engage in disruptive behavior, provided fraudulent information when you enrolled or abuse your enrollment card.

Together with your rights as a CCM Direct member, you also have the responsibility to:

• Understand your coverage and the rules you must follow to obtain care as a member.
• Provide the information your health care provider(s) needs to give you the care you need, and follow the treatment plans and guidance given to you.
• Pay the premiums and co-payments as specified in your plan.
• Inform us of questions, concerns, problems and suggestions you have. Our Customer Service department is available to assist you at 1-800-935-7195. TTY/TDD users should call 1-800-855-2881. Monday through Sunday, 8 a.m. to 8 p.m.

Please access the Evidence of Coverage for more detailed information on all Member Rights and Responsibilities including disenrollment situations and procedures.

Best Available Evidence of Low-Income Subsidy Status

If you believe that you are paying too much for your prescription drugs because CCM does not have the correct low-income subsidy status, please call our Member Services Department. We can help you find out if you should be paying less for your prescription drugs because you are eligible for Medicaid and/or the low-income subsidy. Please visit the following website for more information: http://www.cms.hhs.gov/PrescriptionDrugCovContra/17_Best_Available_Evidence_Policy.asp.

We welcome your inquiries - call us toll free at 1 (877) CCM-8500 or email us

CCM is a member of The Beth Abraham Family of Health Services.

This page last modified on December 1, 2008.