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If you are requesting an exception (including a formulary exception, tiering exception, or an exception from utilization management rules -
such as dosage or quantity limits or step therapy requirements), we will give you our decision no later than 72 hours after we have received
your physician's "supporting statement," which explains why the drug you are asking for is medically necessary. If you are requesting an
exception, you should submit your prescribing physician's supporting statement with the request, if possible. We will give you a decision in
writing about the prescription drug you have requested. If we do not approve your request, we will explain why, and tell you of your right to
appeal our decision. The section "Appeal Level 1" explains how to file this appeal. If you have not received an answer from us within 72 hours
after receiving your request, your request will automatically go to Appeal Level 2, where an independent organization will review your case.
You, your doctor, or your appointed representative can ask us to give a fast decision (rather than a standard decision) by calling us at 1-800-320-5688 (TTY 1-800-258-6810). Or, you can deliver a written request to Medcore HP, 2609 E. Hammer Lane, Stockton, CA 95210. For delivering requests that are made outside of the regular weekday business hours, you can fax the request to 209-320-2318. Be sure to ask for a "fast," "expedited," or "24-hour" review. You may also file your grievance with the Quality Improvement Organization (QIO) called Lumetra. Lumetra will conduct an investigation and communicate its findings and resolution directly to you and to MHP, as well as to any state or federal agency as required by law. Complaints to the QIO must be filed in writing. You can contact Lumetra at One Sansome Street, Ste. 600, San Francisco, CA 94104-4448, (415) 677-2000. Appointed Representative Filing on Your BehalfAs an enrollee in a Medicare Advantage Prescription Drug Benefit Plan, you may appoint any individual (such as a relative, friend, advocate, attorney, physician, or an employee of a pharmacy, charity, state pharmaceutical assistance program or other secondary payor) to act as your representative. A representative who is appointed by the court or who is acting in accordance with State law may also file a request for a coverage determination or appeal on behalf of an enrollee.Should you wish to name someone as your appointed representative you will need to sign, date, and complete an appointment of representative form or similar written statement. If the appointed representative is an attorney, only you, as the enrollee, need to sign the appointment of representative form or similar written statement. The representative statement must include the enrollee's name and Medicare number. You may use the Appointment of Representative Form (Form CMS-1696), or an equivalent written notice. A notice is an "equivalent written notice" if the information contained in the written notice would satisfy the requirements in Form CMS-1696. A signed Form CMS-1696 or other equivalent written notice must be included with each request for a coverage determination or appeal. You can call us at 209-320-2650 or 1-800-320-5688 (TTY 1-800-258-6810) to learn how to name your appointed representative, or if you need assistance completing the required Form or equivalent written statement. For additional information regarding filing an appeal or grievance please refer to our Appeals and Grievances page on this website. Who may ask for a coverage determination?You can ask us for a coverage determination yourself, or your prescribing physician or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor, or anyone else to act for you. Some other persons may already be authorized under State law to act for you. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. This statement must be sent to us at 2609 E. Hammer Lane, Stockton, CA 95210. You can call us at 1-800-320-5688 (TTY 1-800-258-6810) to learn how to name your appointed representative.You also have the right to have an attorney ask for a coverage determination on your behalf. You can contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. |
Forms |
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Request for Medicare Prescription Drug Coverage Determination Appointment of Representative |
Links |
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Prescription Drugs Appeals & Grievances |