Coverage Determinations/Exceptions, Appeals, and Grievances

There are many ways you can request a review or appeal made about your care or the behavior of those providing your care. These take the form of coverage determinations including exceptions, appeals, and grievances.

Appointing a representative (AOR): You may have a representative who is either appointed by you or authorized by the State to act on your behalf in filing a grievance, requesting a coverage determination, or requesting an appeal.

If you have an appointment of representative or would like to appoint one, please fax or mail authorization documentation to the appropriate address listed below. An AOR or any legally appointment of representative documentation needs to be filed for each coverage determination and exception appeal request.

Coverage determinations/exceptions and appeals are decisions we make about your benefits and coverage or about the amount we will pay for your prescription drugs covered under the Part D benefit included in your plan.

Below are examples of coverage determination exceptions you may ask us to make for your Part D drugs:

  • Covering a Part D drug that is not on the plan's List of Covered Drugs (Formulary)
  • Waiving a restriction on the plan's coverage for a drug (such as limits on the amount of the drug you can get)
  • Paying a lower cost-sharing amount for a covered drug on a higher cost-sharing tier
  • Asking whether a drug is covered for you and whether you satisfy any applicable coverage rules
    • For example, when your drug is on the plan's list of covered drugs (Formulary) but we require you to get approval from us before we will cover it for you.
  • Asking us to pay for a prescription drug you already bought: this is a request for a coverage decision about payment

Requesting a coverage determination can be done by online form, phone, mail or fax.

  • Forms: Instructions and forms (online or PDF download) for requesting a drug coverage determination or exception are in the documents section. 
  • About mailing forms: Send mailed forms to the address below. You don't have to have all the information complete on the form before submitting, however, all information will need to be completed for a timely decision.

Coverage determinations and appeals about prescription drugs can be sent to:

MedImpact Healthcare Systems, Inc.
10181 Scripps Gateway Court
San Diego, CA 92131
Fax: 1-858-790-6060
Phone: 1-877-403-6038

Appeals, also called Redeterminations, are a formal way of asking us to review and change a coverage decision we have made. There are five levels of appeals you can make if any part of a request for a coverage determination is denied. Instructions on how to appeal are included if you receive a denial on a coverage determination decision letter or you can call us at 1-888-648-9622. TTY users should call 711.

Grievances are an expression of dissatisfaction with any aspect of Blue MedicareRx operations, activities or behavior of Blue MedicareRx or its delegated entity in the provision of health care items, services, or prescription drugs, regardless of whether remedial action is requested or can be taken. A grievance does not include, and is distinct from, a dispute of the appeal of an organization determination or coverage determination or an late enrollment determination (LEP). You can file a grievance by calling or writing customer service using the contact information below, or directly with Medicare by calling 1-800-MEDICARE, or by using the Medicare online complaint form.

Grievances can be sent to:

MedImpact Healthcare Systems, Inc.
10181 Scripps Gateway Court
San Diego, CA 92131
Phone: 1-877-403-6038 Fax: 1-858-790-6060

You may a request an aggregated number of grievances, exceptions or appeals filed with the plan by contacting our customer service team

Further information and assistance

  • If you have questions or concerns or want to check the status of coverage determinations, appeals, or would like to file a grievance,
  • or questions about making an appointment of representation (AOR)
  • or if you need help in completing the AOR form

Please call Blue MedicareRx customer service at 1-877-853-7693 (TTY: 711), 8 a.m. to 8 p.m., daily, local time.

Acceptable forms of authorization documentation:

  • Power of attorney (POA) documentation
  • Document showing an individual authorized by a court or authorized under State or other applicable law. An authorized individual could include, but is not limited to, a court appointed guardian, an individual with durable power of attorney, a health care proxy, a person designated under a health care consent statute or an executor of an estate. Legal authorization documentation is valid until its expiration date noted in the document, unless revoked.
  • Completed CMS-1696 appointment of representative (AOR) form. A completed AOR form is valid for one year from the date it has signatures for you and your appointee, unless revoked.
  • Equivalent written notice which includes:
    • Your name, address, and telephone number
    • Appointed individual’s name, address, and telephone number
    • Your Medicare beneficiary identifier (MBI) or plan ID number
    • Appointed individual’s professional status or relationship to you
    • Written explanation of the purpose and scope of the representation
    • Statement that you authorize the appointed individual to act on your behalf
    • Statement authorizing disclosure of individually identifying information to the appointed individual
    • Statement by the individual being appointed that they accept the appointment
    • Signature and signature date by you and the individual being appointed. An equivalent notice is valid for one year from the date it has signatures for both you and your appointee, unless revoked