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Exceptions and Appeals

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Coverage determination

The coverage determination is a decision by the plan about whether a drug prescribed for you is covered and the amount, if any, you are required to pay. If you need a drug that is not on the plan’s formulary or you have been using a drug that has been removed during the plan year, use this form to request a formulary exception. You, your doctor, or someone you’ve authorized may make a written or oral request. For more information see section 5 of the Evidence of Coverage for the following plans.

Coverage determination form for enrollees

Coverage determination forms for physicians

Coverage determination instructions

• Keystone 65 Advantage and Preferred Medical-only HMO
• Keystone 65 Advantage and Preferred Rx HMO
• Personal Choice 65^SM Medical-only PPO
• Personal Choice 65 Rx PPO

Prior authorization

The plan requires prior authorization (approval in advance) of certain covered drugs that have been approved by the FDA for specific medical conditions. Contact Us for more information.

Prior authorization for all drug plans

Appeals

If you or your doctor do not agree with the outcome of the initial coverage determination, you or your doctor (on your behalf) may appeal the decision by having your doctor request a redetermination. For more information see section 5 of the Evidence of Coverage for the following plans.

• Keystone 65 Advantage and Preferred Medical-only HMO
• Keystone 65 Advantage and Preferred Rx HMO
• Personal Choice 65^SM Medical-only PPO
• Personal Choice 65 Rx PPO

Grievances

You may file a grievance if you have a complaint other than one that involves a coverage determination (see Appeals above). You would file a grievance if you have any type of problem with us or one of our network pharmacies. Contact Us for more information. For more information see section 4 of the Evidence of Coverage for the following plans.

• Keystone 65 Advantage and Preferred Medical-only HMO
• Keystone 65 Advantage and Preferred Rx HMO
• Personal Choice 65^SM Medical-only PPO
• Personal Choice 65 Rx PPO

Appointment of a representative

You can ask us for a coverage determination or appeal, or your prescribing doctor or someone you name may do it for you. The person you name would be your appointed representative. You may 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:
Member Appeals Unit, PO Box 13652, Philadelphia, PA 19101-3652. You can call the Customer Service Department to learn how to name your appointed representative.

• Appointment of Representative form

Evidence of Coverage

The Evidence of Coverage (EOC) is a comprehensive resource guide to your health care coverage and is considered a legal document. See the EOC for more information on grievance, coverage determination, and appeals processes.

Contact information

Members and providers who have questions about the Exceptions and Appeals processes or would like to inquire about the status of a coverage determination can contact Customer Service.