Medicare Part D
Medicare Coverage for Prescription Drugs
Since January 1, 2006, Medicare has been offering insurance coverage for prescription drugs through Medicare prescription drug plans. Insurance companies and other private companies work with Medicare to offer these plans. These plans will help you save money on your prescription drug costs. Medical practice has come to rely more and more on new drug therapies to treat chronic conditions.
In order to get this prescription coverage, you must choose and enroll in a Medicare prescription drug plan that meets your needs. Here's how you can prepare to take advantage of this option.
- Look over your current health insurance coverage. Are prescription drugs covered? What are your out-of-pocket drug costs?
- Keep a list of the name, dosage, and cost of the prescriptions you use. Since different plans will cover different drugs, this will help you choose a plan that meets your prescription needs.
- If you have a limited income, you may contact the Social Security Administration (SSA) for an application to get extra help paying for a Medicare prescription drug plan. When you get this application, fill it out, and return it. Millions of people will qualify for a Medicare prescription drug plan with little or no premiums or deductibles, and low copayments. You might be one of them.
- If you have prescription drug coverage through a former employer or union, check with your benefits administrator. Medicare prescription drug coverage may be different for you
- Read on to learn about Medicare prescription drug plans
If you don't use a lot of prescription drugs now, you still should consider joining. As we age, most people need prescription drugs to stay healthy. If you do not enroll in Medicare Part D or another plan with creditable coverage (as good as Medicare’s), you may have to pay a late enrollment penalty in addition to your premium for Medicare Part D coverage in the future.
Best Available Evidence (BAE)
The Centers for Medicare and Medicaid Services (CMS) specify the requirements of a Part D sponsor in the administration of the low-income subsidy program, including the reduction of cost sharing for subsidy-eligible individuals. In certain cases, CMS systems do not reflect a beneficiary’s correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan.
To address these situations, CMS created the Best Available Evidence (BAE) Policy in 2006.
Coverage Determinations, Appeals & Grievances
A grievance is an expression of dissatisfaction with the services provided by Retiree RxCare or our contracted providers. If you have a concern regarding the services provided by Retiree RxCare, we encourage you to call us right away by calling our Retiree RxCare Customer Care Department at 1-855-693-3921. Concerns can be conveyed telephonically or through correspondence. In order to exercise this right, you must file your grievance no later than 60 days after the event or incident that precipitated the grievance. Click here for Grievance Policy and Procedure.
Members have the option to request an exception for drug coverage or tier cost sharing. For more detailed information regarding the criteria for exceptions, please call the Retiree RxCare Customer Care Department at 1-855-693-3921, Monday to Friday, 8:00 AM to 8:00 PM.
Standard Re-determination (Appeal) Process
The appeal process deals with an adverse determination regarding Retiree RxCare issuing a denial for a requested drug, service, or claim payment. When submitting your appeal you may include information, which you believe, may help us with the processing of your appeal or help us rule in your favor. Upon completion of our review, a letter will be sent to you advising you of our decision.
An appeal must be filed within 60 days from the date that the determination was rendered. Upon receipt, we will review your appeal and respond within 7 days with our decision.
What to include in the Appeal Request
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 prescribing physician must indicate that all the drugs on any tier of our formulary would not be as effective to treat your condition as the requested off-formulary drug or would harm your health.
An expedited appeal can be requested orally or in writing by the member or by a physician acting on behalf of the member. If a physician supports the request for an expedited appeal, Retiree RxCare will honor this request. If a member submits an appeal without physician support, Retiree RxCare will review the request to determine if it meets Medicare's criteria for expedited processing. If the plan determines that the request meets the expedited criteria, the plan will render a decision as expeditiously as the member's health requires, but not exceeding 72 hours. If the request does not meet the expedited criteria, then we will render a coverage decision with the standard predetermination time frame, 7 days.
Where to Send a Grievance
Customer Care Department
50 Whitecap Drive
North Kingstown , RI 02852
Phone Number: 1-855-693-3921
Where to Send a Coverage Determination
2 Enterprise Drive, Suite 204
Shelton, CT 06484
Fax Number: 1-866-650-3622
Phone Number: 1-855-693-3921
Where to Send an Appeal
C/O Elixir Rx Solutions, LLC
2181 E. Aurora Rd., Suite 201
Twinsburg, OH 44087
Attn: Clinical Services
Expedited appeal requests can be made by phone at 1-866-250-2005.
What Happens Next
If you appeal, we will review your case and give you a decision. If any of the prescription drugs you requested are still denied, you can request an independent review of your case by a reviewer outside of your Medicare Drug Plan. If you disagree with that decision, you will have the right to further appeal. You will be notified of your appeal rights if this happens.
If you need information or help, call us at:
Toll Free: 1-855-693-3921
Other Resources To Help You
Medicare Rights Center
Toll Free: 1-888-HMO-9050
Elder Care Locator
Toll Free: 1-800-677-1116
If you wish to file a complaint with Medicare directly please call 1-800-Medicare (1-800-633-4227) or go to http://medicare.gov/claims-and-appeals/file-a-complaint/complaint.html. TTY: 711
To obtain the number of grievances, appeals and exception filed with Retiree RxCare please send a written request to:
50 Whitecap Drive
North Kingstown, RI 02852
Potential for Contract Termination
Elixir Rx Solutions, LLC, marketed under Retiree RxCare, is contracted with the Centers for Medicare and Medicaid Services (CMS), the government agency that administers Medicare. The contract is subject to renewal each year. Elixir Rx Solutions, LLC or CMS can elect to end the contract at any time. In the unlikely event this happens:
You will be notified in writing of the program’s termination. Depending on the circumstances this can be 90 days or fewer than 30 if CMS discontinues the contract during a plan year.
As soon as you have been notified in writing, you may begin to enroll in another plan. You will need to enroll in another Medicare Prescription Drug Plan or, pending availability, a Medicare Advantage Plan with prescription drug coverage (MA-PD).
All benefits and rules under your Retiree RxCare plan will continue until the last day of your Retiree RxCare membership. You will also continue to receive your prescription drugs in the usual way from Retiree RxCare network pharmacies