• You ask us to pay for a prescription drug you have already received. This is a request for a coverage determination about payment. You can call us at 1-877-677-8203 to get help in making this request.
• You ask for a Part D drug that is not on your plan’s list of covered drugs (called a “formulary”). This is a request for a “formulary exception.” You can call us at 1-877-677- 8203 to ask for this type of decision.
• You ask for an exception to our plan’s utilization management tools - such as dosage limits, quantity limits, or step therapy requirements. Requesting an exception to a utilization management tool is a type of formulary exception. You can call us at 1-877- 677-8203 to ask for this type of decision.
• You ask for a non-preferred Part D drug at the preferred cost-sharing level. This is a request for a “tiering exception.” You can call us at 1-877-677-8203 to ask for this type of decision.
• You ask that we reimburse you for a purchase you made from 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. You can call us at 1-877-677-8203 to make a request for payment or coverage for drugs provided by an out-of-network pharmacy or in a physician’s office. When we make a coverage determination, we are giving our interpretation of how the Part D prescription drug benefits that are covered for members of OSF HealthPlans apply to your specific situation. Your Evidence of Coverage booklet and any amendments you may receive describe some of the Part D prescription drug benefits covered by OSF HealthPlans, including any limitations that may apply to these benefits. Your Evidence of Coverage booklet also lists exclusions (benefits that are “not covered” by OSF HealthPlans).
• For process or status questions concerning coverage determinations, please call Member Services at 309-677-8203, toll free 1-877-677-8203 or for the hearing and speech impaired (TTY) 888-817-0139. Our business office hours are Monday through Friday 8am to 5pm. Our business phone hours are 24 hours a day, 365 days a year.

What is an appeal?
An appeal is any of the procedures that deal with the review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.

Whether you have a grievance, coverage determinations request or appeal on a decision we make concerning your care we want you to understand the policies and processes that apply.

Your Evidence of Coverage book has the following sections for your review.

In Medicare Advantage (Medical Only) EOC Books:

Section 7: How to File A Grievance
Section 8: What to do if you have complaints about your Part D prescription drug benefits

In Medicare Advantage Part D Prescription Drug Plans (Basic Rx, Rx and Rx Plus) EOC Books:

Section 8: How To File A Grievance.
Section 9: Information on how to make a complaint about Part C services
Section 10: What to do if you have Complaints about your Part D prescription drug benefits

Click on your plan name and your EOC book will open in Acrobat Reader.

Appointing a Representative for Appeals
An enrollee may appoint any individual (such as a relative, friend, advocate, an attorney, or any physician) to act as his or her representative when filing a regular appeal or expedited appeal. A representative who is appointed by the court or who is acting in accordance with State law may also file an appeal for an enrollee.

With the exception of incapacitated or legally incompetent enrollees where appropriate legal papers, or other legal authority, support this representation, both the enrollee making the appointment and the representative accepting the appointment must sign, date, and complete an appointment of representative form. If the appointed representative is an attorney, only the enrollee needs to sign the appointment of representative form or similar statement.

The representative statement must include the enrollee’s name and Medicare number. The enrollee may use Form CMS-1696 found online by clicking here. A signed form or statement must be included with the enrollee’s appeal. A separate appointment of representative form or statement is required for each appeal.

Required Links:

Request for Medicare Prescription Drug Coverage Determination.

Medicare Part D Coverage Determination Request Form for use by providers.

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