Part D Appeals

Another protection for enrollees is the right to file an appeal. Please refer enrollees to our plan's Evidence of Coverage if you are asked about an appeal.

If you or the enrollee disagrees with any restriction, limitation, or denial of an exception request (or other prescription) or denial of a prior authorization, or if Care Improvement Plus fails to provide a timely decision about a prescription, the member has the right to file an appeal in writing to the address/fax below. If the restriction or denial could jeopardize the enrollee's health status, an expedited appeal may be requested by phone or fax.

You, as the prescribing physician, may request an appeal on behalf of a Medicare enrollee. You do not have to have legal authorization from the enrollee to request a drug coverage appeal.

The first level of a prescription drug appeal is also called a "redetermination" and is conducted by the plan's pharmacists and physicians.

Timelines for completing an appeal are prompt. Care Improvement Plus must gather information and make a determination within a 7-day time period for standard appeals or within 72 hours for expedited appeals.

If Care Improvement Plus upholds its initial denial, a written notice is issued, including information on how to file an appeal at the next level. The next level is a "reconsideration" by an independent reviewer under contract with the Medicare program Independent Review Entity. A Request for Reconsideration Form should

Appeals
To obtain a standard appeal, send appeal request in writing to Care Improvement Plus:

By mail:
Care Improvement Plus
351 West Camden Street, Suite 100
Baltimore, MD 21201
Attn: Pharmacy Appeals

By fax for pharmacy appeals: 1-866-683-3272

To obtain an expedited appeal:
By phone: 1-866-683-3275 (TTY: 1-800-713-1603)
By fax: 1-866-683-3272