Appeal for Drug Coverage

Step-by-step: How to make a Level 1 Appeal for Drugs

How to ask for a review of a coverage decision made by our plan

Step 1: You contact us and make your Level 1 Appeal. If your health requires a quick response, you must ask for a “fast appeal.”

What to do
  • To start your appeal, you (or your representative or your doctor or other prescriber) must contact us.
  • If you are asking for a standard appeal, make your appeal by submitting a written request. You may also ask for an appeal by calling us.
  • If you are asking for a fast appeal, you may make your appeal in writing or you may call us.
  • We must accept any written request, including a request submitted on the CMS Model Coverage Determination Request Form, which is available on our website.
  • You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision.
  • You can ask for a copy of the information in your appeal and add more information.
    • You have the right to ask us for a copy of the information regarding your appeal.
    • If you wish, you and your doctor or other prescriber may give us additional information to support your appeal.

Method

Appeals for Part D Prescription Drugs – Contact Information

Call

1-888-254-9907
Calls to this number are free. Hours are 8 a.m. to 8 p.m., seven days a week from October 1 through March 31, except holidays, and 8 a.m. to 8 p.m., Monday through Friday, from April 1 through September 30, except holidays. Messages received on holidays and outside of our business hours will be returned within one business day.

TTY

711
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.

Fax

1-858-790-6060

Write

MedImpact HealthCare Services
Attn: Appeals Coordinator
10181 Scripps Gateway Ct.
San Diego, CA 92131

Click here to download the Appeal Form (Redetermination Request form) for Drugs: English | Spanish
Download Adobe Acrobat Reader

For expedited requests, please call or fax using the contact numbers above.

If your health requires it, ask for a “fast appeal”
  • If you are appealing a decision we made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a “fast appeal.”
  • The requirements for getting a “fast appeal” are the same as those for getting a “fast coverage decision” in Section 6.4 of this chapter.

Step 2: We consider your appeal and we give you our answer.

  • When we are reviewing your appeal, we take another careful look at all of the information about your coverage request. We check to see if we were following all the rules when we said no to your request. We may contact you or your doctor or other prescriber to get more information.
Deadlines for a “fast appeal”
  • If we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it.
  • If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 72 hours after we receive your appeal.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no and how to appeal our decision.
Deadlines for a “standard appeal”
  • If we are using the standard deadlines, we must give you our answer within 7 calendar days after we receive your appeal for a drug you have not received yet. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so. If you believe your health requires it, you should ask for “fast appeal.”
  • If our answer is yes to part or all of what you requested –
    • If we approve a request for coverage, we must provide the coverage we have agreed to provide as quickly as your health requires, but no later than 7 calendar days after we receive your appeal.
    • If we approve a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive your appeal request.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no and how to appeal our decision.
  • If you are requesting that we pay you back for a drug you have already bought, we must give you our answer within 14 calendar days after we receive your request.
  • If our answer is yes to part or all of what you requested, we are also required to make payment to you within 30 calendar days after we receive your request.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how to appeal.

Step 3: If we say no to your appeal, you decide if you want to continue with the appeals process and make another appeal.

  • If we say no to your appeal, you then choose whether to accept this decision or continue by making another appeal.
  • If you decide to make another appeal, it means your appeal is going on to Level 2 of the appeals process (see below).

Step-by-step: How to make a Level 2 Appeal

If we say no to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Organization reviews the decision we made when we said no to your first appeal. This organization decides whether the decision we made should be changed.

Step 1: To make a Level 2 Appeal, you (or your representative or your doctor or other prescriber) must contact the Independent Review Organization and ask for a review of your case.

  • If we say no to your Level 1 Appeal, the written notice we send you will include instructions on how to make a Level 2 Appeal with the Independent Review Organization. These instructions will tell who can make this Level 2 Appeal, what deadlines you must follow, and how to reach the review organization.
  • When you make an appeal to the Independent Review Organization, we will send the information we have about your appeal to this organization. This information is called your “case file.” You have the right to ask us for a copy of your case file.
  • You have a right to give the Independent Review Organization additional information to support your appeal.

Step 2: The Independent Review Organization does a review of your appeal and gives you an answer.

  • The Independent Review Organization is an independent organization that is hired by Medicare. This organization is not connected with us and it is not a government agency. This organization is a company chosen by Medicare to review our decisions about your Part D benefits with us.
  • Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal. The organization will tell you its decision in writing and explain the reasons for it.
What if the review organization says no to your appeal?

If this organization says no to your appeal, it means the organization agrees with our decision not to approve your request. (This is called “upholding the decision.” It is also called “turning down your appeal.”)

If the Independent Review Organization “upholds the decision” you have the right to a Level 3 Appeal. However, to make another appeal at Level 3, the dollar value of the drug coverage you are requesting must meet a minimum amount. If the dollar value of the drug coverage you are requesting is too low, you cannot make another appeal and the decision at Level 2 is final. The notice you get from the Independent Review Organization will tell you the dollar value that must be in dispute to continue with the appeals process.

Step 3: If the dollar value of the coverage you are requesting meets the requirement, you choose whether you want to take your appeal further.

  • There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal).
  • If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal. If you decide to make a third appeal, the details on how to do this are in the written notice you got after your second appeal.
  • The Level 3 Appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.

For more information on the drug coverage appeal process, you may refer to Chapter 9 Section 6 of the Evidence of Coverage (EOC).

You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to file a grievance, request a coverage decision, or make an appeal at any level of the process. Go to “How to Appoint a Representative” page to find out more.

You may ask to obtain the aggregate numbers of the plan’s grievances, appeals, and exceptions. Please contact Vitality Member Services Department at 1-866-333-3530 (TTY: 711). Hours are 8 a.m. to 8 p.m., seven days a week from October 1 through March 31, except holidays, and 8 a.m. to 8 p.m., Monday through Friday, from April 1 through September 30, except holidays. Messages received on holidays and outside of our business hours will be returned within one business day.

Last updated 12/20/2018