If you have a received a decision from Medicare Plus Blue PPOSM or Prescription Blue PDPSM that indicates we will not pay for a drug or service you believe you are entitled to or you believe we have not paid for the drug or service as you anticipated you may ask us to reconsider or appeal our coverage decision.
The first step is to call Member Services at the number printed on the back of your ID card.
Our representatives may be able to:
- Provide information about why a drug or service is being denied prior to receiving it.
- Help you to understand how your drug or service was processed.
If, after speaking with a Member Services representative, you still wish to file an appeal for a drug, you may advise the representative verbally, and he or she will document your request and forward it to the Grievance and Appeals Department.
If, after speaking with a Member Services representative, you still wish to file an appeal for a service or item, you may only do so in writing using the address or fax number indicated below.
If you are unable to file your own appeal, you may appoint someone like your spouse, child, neighbor or friend to act on your behalf.
If you do not want to call, or if your appeal is a request for a service or item that must be filed in writing, you should complete these steps to initiate your appeal:
- Describe what you would like to appeal, and, if possible include a copy of the denial that you received.
- Include your name, member ID, a daytime telephone number and signature.
Send the information to us:
By mail:
Blue Cross Blue Shield of Michigan
Grievance and Appeals Department
P.O. Box 2627
Detroit, MI 48231-2627
By fax:
1-877-348-2251
We will generally use the standard timelines for responding. This means we will generate a response to you:
- Within seven days of receipt if you are appealing a decision for a drug
- Within 30 days of receipt if you are appealing a decision for a service you have not yet received
- Within 60 days of receipt for a service or drug you have received.
Certain situations allow you to request a "fast decision" about whether or not Medicare Plus Blue PPOSM or Prescription Blue PDPSM will pay for the service. You can only ask for a "fast decision" when:
- You are asking about a service or drug you have not yet received, and
- Using the standard timelines could cause serious harm to your health or hurt your ability to function.
The information above is a brief summary. Refer to your Evidence of Coverage for complete information about your rights, benefits and responsibilities (Chapter 9 for Medicare Plus Blue PPOSM members; Chapter 7 for Prescription Blue PDPSM members).
For expedited requests ("fast decisions") only, you may call 1-877-241-2583, 8 a.m to 8 p.m, 7 days a week. TTY users may call 1-800-579-0235. You may also fax to 1-877-348-2251.
H9572 S5584_W_BCBSMAdvantageWebR1 CMSApproved 05242011
People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for up to seventy-five (75) percent of drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don't even know it. For more information about the Extra Help program, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days per week. TTY users should call 1-877-486-2048.
Important information about these plans
Medicare Plus Blue PPOSM is a health plan with a Medicare contract. Prescription Blue PDPSM is a stand-alone prescription drug plan with a Medicare contract.
Medicare Plus Blue PPO
Medicare Plus Blue PPO is available to all Medicare beneficiaries who are Michigan residents and are entitled to receive services under Medicare Part A and enrolled in Part B.
With the exception of emergency or urgent care, it will cost more to get care from non-plan or non-preferred providers. Your responsibility will be greater out-of-network when the out-of-network coinsurance is based on the Medicare allowed amount and the contracted amount is lower. You may receive services from any provider who accepts Original Medicare. Your out-of-pocket costs will be lower if you choose a network provider. To find a network provider, visit www.bcbsm.com/medicare/provdirectory.shtml.
Prescription Blue PDP
Prescription Blue PDP is available to all Medicare beneficiaries who are Michigan residents entitled to receive services under Medicare Part A and/or enrolled in Part B.
Medicare Plus Blue PPO and Prescription Blue PDP
Premiums vary by county. You must continue to pay your Medicare Part B premium.
Limitations, copayments and restrictions may apply.
Our network includes approximately 2,300 Michigan retail pharmacies, of which 86 percent are network pharmacies. Nationwide, most chain pharmacies are in our network, as well as long-term care and home infusion pharmacies and Indian/Tribal/Urban (Indian Health Service) pharmacies.
In general, benefits are only available at contracted network pharmacies. Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost sharing amount if you get your drugs at an out-of-network pharmacy. Quantity limitation and restrictions may apply. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Blue Cross Blue Shield of Michigan. For additional information on network pharmacies, please call Member Services at 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704. You may also write to: Blue Cross Blue Shield of Michigan, 600 E. Lafayette Blvd., Mail Code X435, Detroit, MI 48226.
If you decide to have your plan premium withheld from your Social Security check or deducted from your checking or savings account, it may take up to three months for the automatic deduction to begin. If your premium amount is currently withheld from your Social Security check or deducted from your checking or savings account and you wish to receive a monthly bill instead, the change may also take up to three months to become effective. During this time, you will be responsible for paying your premium.
The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on Jan. 1, 2013.
Medicare beneficiaries may enroll in Medicare Plus Blue PPO, BCN Advantage HMO-POS or Prescription Blue PDP through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. For more information, please contact Blue Cross Blue Shield of Michigan at 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704.
You may only enroll in Medicare Plus Blue PPOSM or Prescription Blue PDPSM during specific times of the year. To learn more about enrollment periods, please contact Member Services.
