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Clear Care HMO and PPO Part D Drug Formulary: Exceptions, Appeals, and Grievances

Exceptions to the Formulary

You can ask us to cover a non-formulary drug, or to waive coverage restrictions or limits on a drug. For example, for certain drugs, Group Health Cooperative and Group Health Options, Inc. limits the amount of the drug that we will cover. If the prescribed drug has a quantity limit, you can ask us to waive the limit and cover more.

A formulary exception may be requested by you or your appointed representative (see details below) and the prescribing physician. A request can be submitted by phone, fax, or mail.

Requesting an Exception (Members)
Send to:
Group Health Cooperative
Pharmacy Drug Benefit Help Desk
P.O. Box 34990
Seattle, WA 98124-1990
1-888-901-4600 (toll-free)
1-866-510-1765 (toll-free fax)
206-901-4617 (fax)

  • 1. Download and print the Request for Medicare Prescription Drug Coverage Determination (PDF), or call Customer Service and request that the form be sent to you. Also see: Form Instructions (PDF)
  • 2.Complete the entire form and submit either by fax or mail.
  • 3.Your physician must submit a statement that none of the drugs used to treat your condition in Group Health's formulary would be as effective, and/or that all of the formulary drugs have caused you adverse effects.
  • 4. To check the status of your exception request, please contact Customer Service.

For coverage requests after an initial denial, you will need to use this form: Request for Redetermination of Medicare Prescription Drug Denial (PDF)

Requesting an Exception (Physicians)
Send to:
Group Health Cooperative
Pharmacy Solution Center
P.O. Box 34589
Seattle, WA 98124-1589
206-901-4196, 1-888-301-1915 (toll-free)
206-901-4617 (fax)
1-866-510-1765 (fax)

  • 1. Download and print the Request for Medicare Prescription Drug Coverage Determination (PDF). Also see: Form Instructions (PDF) Or provide a statement that none of the drugs used to treat your patient's condition in Group Health's formularies would be as effective, and/or that all of the formulary drugs have caused adverse effects for your patient.
  • 2. Submit all materials either by fax or mail.
  • 3. To check the status of your exception request, please contact the Group Health Pharmacy Solution Center at the number above.

Once Group Health receives the physician's statement, the decision-making time period begins. Group Health will have 72 hours (for a standard request) or 24 hours (for an expedited request) to notify you of our decision. The request will be expedited if your doctor tells Group Health that your life or health will be seriously jeopardized by waiting for a standard response.

For coverage requests after an initial denial, you will need to use this form: Request for Redetermination of Medicare Prescription Drug Denial (PDF)

How to Request an Appeal/Redetermination

If Group Health denies a request for coverage of a drug, you have the right to request an appeal. You must request this appeal within 60 days from the date notice of the denial, reduction or discontinuation of coverage.

An appeal may be requested by a patient or an authorized representative (see details below) and the prescribing physician. Please include: Member name, address, member ID number, reasons for requesting an exception, and any evidence you wish to attach. A request for an appeal redetermination may be submitted by fax, mail, or in person.

Fax
206-901-7340

Mail
Group Health Cooperative
Group Health Member Appeals Department
Attn.: Appeals Coordinator
P.O. Box 34593
Seattle, WA 98124-1593

In person
12400 E. Marginal Way S.
Seattle, WA 98168-2559

Online
Alternatively, you can fill out a form online, but to protect the security of personal information, you must log in to MyGroupHealth for Members.
Online Member Appeals Request form

Once Group Health receives the request for an appeal, we have seven days (for a standard request for coverage or for a request to pay the member back) or 72 hours (for an expedited request for coverage) to notify the member of our decision. The member's request will be expedited if a physician confirms that your life or health will be seriously jeopardized by waiting for a standard decision.

For information on the status of your appeal redetermination request, please contact the Group Health Appeals department at 206-901-7359 or toll-free 1-866-458-5479.

Filing a Grievance

A grievance is any complaint or dispute regarding an organization's or a provider's operations, activities, or behavior. Grievances do not include denial or discontinuation of health care services, or denial of claims.

Examples or possible subjects of grievances:

  • Complaints concerning the quality of care or services provided (not related to payment or coverage)
  • Interpersonal aspects of care, such as rudeness by a provider or staff member
  • Failure to respect a patient's rights
  • Complaints regarding copays
  • Membership, enrollment, or dues issues

To file a grievance, contact Group Health Customer Service at 1-888-901-4600 toll-free or send a fax to 206-901-6205. You can also contact us by mail:

Group Health Cooperative
Customer Service
P.O. Box 34590
Seattle, WA 98124-1590

Grievances must be filed no later than 60 days after the incident in question.

Group Health will review the complaint and respond as quickly as the case requires, but no later than 30 days after the grievance is received. A 14-day extension is allowed if you request it, or if Group Health needs time to gather more information and can show that the delay is in your interest. Group Health must notify you of the delay in writing.

Group Health will respond within 24 hours to these types of grievances:

  • Complaint about Group Health's refusal to grant a request for an expedited coverage decision and you have not yet purchased or received the drug in question.
  • Complaint involving Group Health's decision to extend the deadline (up to 14 days) to respond to a grievance.

Authorized Representatives

You can ask anyone you want to help you with your Medicare prescription drug plan. If this person agrees to help you in this way, she or he is your authorized representative. Your authorized representative can be someone appointed to make decisions for you, such as a guardian or health care proxy, or attorney-in-fact.

If someone else will be filing a grievance or requesting an exception or an appeal on your behalf, please complete the following form and submit along with other supporting documentation.

Evidence of Coverage Documents (EOCs)

For complete information on grievance, coverage determination (including exceptions), and appeals processes, you can refer to your Evidence of Coverage. For the Clear Care Basic Plan, reference Chapter 7 and for all other plans, Chapter 9.

Medicare Complaint Form

Use this electronic form if you wish to file a complaint directly with Medicare, instead of with Group Health. You can also contact the Medicare Ombudsman for assistance with complaints, grievances and information requests.

For More Information

Please contact Customer Service at 1-888-901-4600 (TTY only, call 1-800-833-6388 or 711). Hours are Monday-Friday, 8 a.m.- 8 p.m. From Oct. 1 through Feb. 14, hours are daily, 8 a.m.-8 p.m.

You can also refer to your Explanation of Coverage (EOC).

If you have questions about the process, or about the status of your Exception Request, Grievance or Appeal, please call Customer Service. Providers may call the Provider Assistance Unit at 509-241-7206.

To obtain information on the aggregate number of grievances, appeals, and exceptions filed with us, please contact Customer Service at the numbers above.

Also see: Medicare Advantage Clear Care HMO and PPO Part D Drug Formulary

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