Grievance, appeals and exceptions
To check the status of an appeal, grievance or a coverage determination
request, please call our Customer Service Department at the numbers shown
on this page.
As a Medicare beneficiary, you have the right to file an appeal, grievance or exception if you are unhappy with any of the benefits or services you are receiving.
The coverage determination we make is the starting point for dealing with requests you may have about covering or paying for a Part D prescription drug. If your doctor or pharmacist tells you that a certain prescription drug is not covered you should contact us and ask us for a coverage determination.
The following are examples of coverage determinations:
An exception is a type of coverage determination. You can ask us to make an exception to our coverage rules in a number of situations.
As a Medicare beneficiary, you have the right to file an appeal, grievance or exception if you are unhappy with any of the benefits or services you are receiving.
Grievances
- You would file a "grievance" for any complaint or dispute
you have, other than one that involves a coverage determination. Grievances
are things such as if you have a problem with things such as waiting
times when you fill a prescription, the way your network pharmacist
or others behave, being able to reach someone by phone or get the information
you need, or the cleanliness or condition of a network pharmacy.
If you have a grievance, we encourage you to first call Customer Service at the numbers shown on the top of this page. We will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond in writing to you.
If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this a "formal complaintreview". You, your representative, or your physician must file the formal complaint review no later than 60 days after the event or incident that precipitates the grievance. Upon receipt of your request for a formal compliant review, we will promptly determine and inform you whether the complaint is subject to the grievance procedures or the appeal procedures. At this time we will also determine if your grievance is subject to our fast (expedited) grievance procedures. If it is we, will notify you our decision within 24 hours of your request. We will respond to you orally, and where applicable, will follow-up in writing. Please see the Customer Service contact section.
For standard grievances, we must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint.
With both standard and fast grievances, we may extend the 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.
Written grievances should be mailed to us at 1277 Deming Way, Madison, WI 53717 or via fax at (608) 830-5920.
Coverage Determinations
The coverage determination we make is the starting point for dealing with requests you may have about covering or paying for a Part D prescription drug. If your doctor or pharmacist tells you that a certain prescription drug is not covered you should contact us and ask us for a coverage determination.
The following are examples of coverage determinations:
- You ask us to pay for a drug you have already received. This is a request
for a coverage determination about payment.
- You ask for a Part D drug that is not on your plan sponsor’s list of
covered drugs (called a "formulary"). This is a request for a "formulary
exception."
- You ask for an exception to our utilization management tools - such as prior
authorization, dosage limits, quantity limits, or step therapy requirements. Requesting
an exception to a utilization management tool is a type of formulary exception.
- You ask us to reimburse you for the cost of a drug you bought at an out-of-network
pharmacy. In certain circumstances, out-of-network purchases, including drugs provided
to you in a physician’s office, will be covered by the plan.
- All requests can be mailed to us at 999 Fourier Drive, Suite 301, Madison, WI 53717 or via fax at (920) 735-5355. You may also call us at the telephone numbers shown on the top of this page for help or information in filing a request.
Exceptions
An exception is a type of coverage determination. You can ask us to make an exception to our coverage rules in a number of situations.
- You can ask us to cover your drug even if it is not on our formulary.
Excluded drugs cannot be covered by a Part D plan unless coverage is through
an enhanced plan that covers those excluded drugs.
- You can ask us to waive coverage restrictions or 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 provide a higher level of coverage for your drug. If
your drug is contained in our highest tier subject to the tiering exceptions
process, you can ask us to cover it at the cost-sharing amount that applies to
drugs in a lower tier instead. This would lower what you must pay for your drug.
Please note, if we grant your request to cover a drug that is not on our formulary,
you may not ask us to provide a higher level of coverage for the drug.
- When
you file an exception, please submit a letter in writing, or you may
print and complete a coverage determination/medical exception form (PDF), along with your prescribing doctors “supporting
statement” which explains why the drug you are asking for is medically
necessary. You can fax the written request to us at (920) 735-5355 or
deliver it to DeanCare Rx, 1277 Deming Way, Madison, WI 53717. We must
make our decision no later than 72 hours after we have received your
prescribing doctor's “supporting statement.”
- If you are asking for a fast decision, be sure to ask for a “fast,”
“expedited” or “24-hour” review. For fast decisions occurring on weekends
or holidays, you may call the Expedited Phone line at 1-800-576-8773.
You will receive a message of how to obtain a 5-day fill. Or, you will
have the option to leave a message or not. If you leave a message, a
page is sent to the on-call pharmacist who will determine if it is an
expedited request.
2010 - COMING SOON- 2010 Complete Classic Formulary
- 2010 Complete Value Formulary
- 2010 Complete Enhanced Formulary
- View a listing of our provider Prior Authorization forms
2009- 2009 Complete Classic Formulary
- 2009 Complete Value Formulary
- 2009 Complete Enhanced Formulary
- View a listing of our provider Prior Authorization forms
A member’s appointed representative, or the prescribing physician may request a review of a coverage decision. If Dean Health Insurance, Inc. fails to provide a coverage determination in a timely manner, when a delay would adversely affect the health of the member, a review may also be requested. For situations in which applying the standard review procedure may seriously jeopardize the enrollee's life, health, or ability to regain maximum function, an expedited review may be requested.
Appeals
You can generally "appeal" our decision not to cover a drug, vaccine, or other Part D benefit. You may also appeal our decision not to reimburse you for a Part D drug that you paid for. You can also appeal if you think we should have reimbursed you more than you received or if you are asked to pay a different costsharing amount than you think you are required to pay for a prescription. Finally, if we deny your exception request, you can appeal. A coverage determination, may be appealed if you disagree with our decision.
You need to file your appeal within 60 calendar days from the date included on the notice of our coverage determination. We can give you more time if you have a good reason for missing the deadline. To file a standard appeal, you can call us at 1-888-422-3326 or TTY 1-877-733-6456 or send the appeal to us in writing at DeanCare Rx, 1277 Deming Way, Madison, WI 53717.
After we get your appeal, we have up to 7 calendar days to give you a decision, but will make it sooner if your health condition requires us to. If we do not give you our decision within 7 calendar days, your request will automatically go to the second level of appeal, where an independent organization will review your case.
You, your doctor, or your appointed representative can ask us to give a fast appeal (rather than a standard appeal) by calling our Customer Service numbers or, you can deliver a written request to the above address. Or you can fax it to us at (608) 830-5920 during or outside our regular business hours. Be sure to ask for a “fast,” "expedited," or “72-hour” review. Remember, that if your prescribing doctor provides a written or oral supporting statement explaining that you need the fast we will automatically treat you as eligible for a fast appeal.
Appointing a 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. To appoint a representative, please click on, print, and fill out this “Appointment of Representative” form (PDF). Please complete the form in its entirety. The first two sections require member and physician information. The third section is where you check a box describing the type of request you are filing. If you need assistance with this section, you may contact our Customer Service Department, at the numbers shown on the top of this page, or you may refer to your Evidence of Coverage (shown below). You must mail the form to us. You can send it to 1277 Deming Way, Madison, WI 53717.
If you are a DeanCare Rx member, please refer to Section 8 of the Evidence of Coverage for detailed information and processes.
2009- 2009 Classic Evidence of Coverage (PDF)
- 2009 Value Evidence of Coverage (PDF)
- 2009 Enhanced Evidence of Coverage (PDF)
- View the 2008 Classic Evidence of Coverage
- View the 2008 Value Evidence of Coverage
- View the 2008 Enhanced Evidence of Coverage
If you would like information on an aggregate number of grievances, appeals and exceptions that Dean Health Insurance has had, please contact our Customer Service Department at the phone numbers shown on the top of this page.
S5954_WEB10_1010 10/22/2009