For certain prescription drugs, HealthSpring requires prior authorization. This means that your doctor must get HealthSpring’s approval before prescribing it to you. If your doctor does not get approval, the drug may not be covered. 
 
These requirements ensure that our members use these drugs in the most effective way. A team of doctors and pharmacists developed these requirements to help us provide quality coverage to our members.
 
 
What if my drug is not on the formulary?

If your prescription is not listed on the formulary, you should first contact Customer Service to be sure it is not covered. If Customer Service confirms that we do not cover your drug, you have three options:

• You can ask your doctor if you can switch to another drug that is covered by us. If you’d like to give your doctor a list of covered drugs that are used to treat similar medical conditions, please contact Customer Service.
  
• You can ask us to make an exception to cover your drug. For more information, read the following section, “How do I request an exception to the plan’s formulary?”
  
• You can pay out-of-pocket for the drug and request that the plan reimburse you by means of an exceptions request. This does not obligate the plan to reimburse you if the exception request is not approved.

How do I request an exception to the plan’s formulary?

You can ask HealthSpring to make an exception to our coverage rules. Several types of exceptions are:

• You can ask us to cover a drug that is not on our formulary.
• You can ask us to waive limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
• You can ask us to waive coverage restrictions on your drug. For example, for certain drugs, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. If your drug has a step therapy requirement, you can ask us to waive the coverage restriction.

Generally, we will approve your request for an exception only if the alternative drugs included on the plan’s formulary or the low-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.


Part D Appeals

How do I request an appeal?

If you are unhappy with an unfavorable coverage determination, you may request an appeal. You should include your name, address, Member ID number, the reasons for appealing, and any evidence you wish to attach. If your appeal relates to a decision by us to deny a drug that is not on our formulary, your physician must indicate that all the drugs on any tier of our formulary would not be as effective in treating your condition as the requested off-formulary drug or would harm your health. If your appeal relates to a decision by us to deny a drug that has restrictions or coverage limits, your physician must submit a supporting statement for the medical necessity of the drug.

For more details about grievance, coverage determination (including exceptions) and appeals process, refer to Chapter 9 of the Medicare Advantage Plans with Prescription Drug coverage of your EOC or Chapter 7 of the Medicare Advantage Plan without Prescription Drug coverage and the stand-alone Prescription Drug plan of your EOC.  You can find your EOC by going to the home page, enter your zip code, and click on the link to your plan.

For a standard appeal, you should mail your written appeal request to the address below:

Part D Appeals/Grievances
P.O. Box 24207
Nashville, TN 37202

Toll-free: 1-866-845-6962
Toll-free fax: 1-866-593-4482
Local fax: 1-615-234-6790

Toll-free TTY: 1-866-845-7230
Local TTY: 711
Hours of operation: 8 am to 8 pm, CST - 7 days a week

You can request an expedited (fast) appeal if you or your doctor believes that your health could be seriously harmed by waiting up to 7 days for a decision. For an expedited appeal, you should contact us by telephone or fax at the numbers below:

Toll-free: 1-866-845-6962

Toll-free fax: 1-866-593-4482

Hours of operation: 8 am to 8 pm, CST - 7 days a week

What is a grievance?

Grievance: Any complaint or dispute, other than one that involves a coverage determination, expressing dissatisfaction with any aspect of the operations, activities, or behavior of a Part D plan sponsor, regardless of whether remedial action is requested. A grievance may also include a complaint that a Part D plan sponsor refused to expedite a coverage determination or redetermination. Grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided item. Additional examples of grievance complaints include the following issues: fraud and abuse, enrollment/disenrollment, benefits packages, pharmacy access/network, marketing, customer service, confidentiality/privacy, and quality of care issues.

What is an Appointed Representative?

Appointed Representative: An individual either appointed by an enrollee or authorized under State or other applicable law to act on behalf of the enrollee in obtaining a coverage determination or in dealing with any of the levels of the appeals process. Unless otherwise stated in part 423, subpart M of the Medicare Part D regulations, the appointed representative has all of the rights and responsibilities of an enrollee in obtaining a coverage determination or in dealing with any of the levels of the appeals process, subject to the rules described in part 422, subpart M of the Medicare Part C regulations. The variation of state law is considered when accepting the authority of appointed representatives.

A Medication Therapy Management (MTM) Program is a free service we may offer. You may be identified to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. The MTM program may have limited eligibility criteria. If you need additional information, please contact HealthSpring member services, 8 a.m. to 8 p.m., CST, 7 days a week, toll free at 1-800-280-8888. TTY/TDD users call 711.

Your Right to a Fast Appeal

If you’re getting Medicare services from a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility, or hospice, and you think your Medicare-covered services are ending too soon, you have the right to a fast appeal. Your provider will give you a notice before your services end that will tell you how to ask for a fast appeal. You should read this notice carefully. If you don’t get this notice, ask your provider for it. With a fast appeal, an independent reviewer, called a Quality Improvement Organization (QIO), will decide if your services should continue.

• You may ask your doctor for any information that may help your case if you decide to file a fast appeal.
• You must call your local QIO to request a fast appeal no later than the time shown on the notice you get from your provider. Use the telephone number for your local QIO listed on your notice.
• If you miss the deadline, you still have appeal rights.  Contact HealthSpring for more information.
   

What is Best Available Evidence? 
 
The Centers for Medicare & Medicaid Services (CMS) requires that all plan sponsors accept evidence presented by a Medicare beneficiary that he or she is eligible for extra help/ Low Income Subsidy (LIS) even if Medicare records show otherwise. Once a beneficiary submits the Best Available Evidence to HealthSpring, we will request that CMS update the beneficiary's LIS status in the CMS system.

Acceptable forms of Best Available Evidence include:

• Medicaid Card - a copy of the card including your name and eligibility date
• Contact Report - a report of the contact including the date a verification call was made to the State Medicaid agency to verify the Medicaid status
• State Document - a copy of a state document confirming active Medicaid status
• State Electronic Enrollment File
• Social Security Administration (SSA) Award Letter 

For more information on BAE Policy by CMS, click here.