Appeal a Determination
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.
HOW TO REQUEST AN APPEAL LEVEL 1
If we deny your request we will send you a written decision explaining why your request was denied. If a coverage determination does not give you all that you requested you have the right to appeal the decision. You need to file your appeal within 60 calendar days from the date included on the notice of our coverage determination. We may give you more time if you have a good reason for missing the deadline. How you make your appeal and who can file the appeal depends upon whether you are requesting reimbursement for a drug you have already received and paid for (Standard Appeal) or authorization of a Part D drug that you have not yet received (Standard or Fast Appeal). For a drug you have not received, you and/or your physician will need to decide whether you need a standard or fast appeal.
The following are the kinds of decisions that can be appealed:
- We do not cover a Part D drug you think you are entitled to receive
- We do not pay you back (reimburse you ) for a Part D drug that you paid for
- We paid you less for a Part D drug than you think we should have paid you
- We ask you to pay a higher co-payment amount other than you think you are required to pay
- We deny your exception request.
Appeals regarding requests for an exception need to have a supporting statement from the prescribing physician. This statement may be written or oral and should/needs to be received by our Member Services Department at the number(s) and address listed below at the time of the Appeal.
WHO MAY REQUEST AN APPEAL
For a Standard Appeal Level 1 You or your appointed representative may file the request.
For a Fast Appeal Level 1: You, your appointed representative our your doctor may file your request.
To file your Appeal Level 1 orally please call FHCP's Member Services Department at 386-615-4022 or 1-877-615-4022. From November 15 though March 1 of each year the hours of operation are 7 days a week, 8 a.m. to 8 p.m. From March 2 through November 14 of each year the hours of operation are Monday through Friday 8a.m.to 8p.m. Hearing impaired may call TTY at 1-877-260-8312.
You may also submit your appeal/redetermination in writing to:
Florida Health Care Plans
Attn: Member Services
1340 Ridgewood Avenue
Holly Hill, FL 32117
Fax: 386-676-7149
If you want someone to act for you then, unless that person has already been appointed under State Law to act on your behalf, you and that person must sign and date the Appointment of Representative form that gives the person legal permission to be your appointed representative. This Appointment of Representative form must be included with the redetermination request.To access the document(s) Adobe Reader® must be installed on your computer. If you do not have Adobe Reader ®, you can download it for free by clicking here.
- Members of the Medvantage Rx & Rx Plus Plans please refer to Section 5 of your Evidence of Coverage for complete information regarding appeals.
