The following is a brief description of what to do when you have a problem or complaint. For a complete description refer to your evidence of coverage, Chapter9. A link to the Evidence of Coverage can be found at the end of this document.

How to ask for coverage of a Part D drug

How to submit a claim for Part D Medication

When you go to a network pharmacy, your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy, you will have to pay the full cost when you fill your prescription. We cover drugs filled at an out-of-network pharmacy in limited circumstances. But, you can ask us to reimburse you for our share of the cost by submitting a claim form. Please call our Member Services Department at 1-866-255-4795 between the hours of 8:00 a.m. and 8:00 p.m. and ask for a Prescription Drug Claim Form. (For TTY call 1-866-321-5955).

Standard decisions about coverage of a Part D drug

When you ask us to cover a Part D drug we will give you a decision within 72 hours. This is called a standard decision about coverage of a Part D drug.

Fast decisions

You may ask us for a fast review if you believe waiting the standard time frame would cause harm to your health. If you ask for a fast review without support from your doctor we will decide whether your request requires a fast decision. If your doctor asks for a fast review for you and indicates that waiting the standard timeframe would cause harm to your health, we will automatically give you a fast decision. If we grant you a fast review, we will make a decision about your request within 24 hours of our receipt of your request.

If we determine your request does not meet the rules for a fast review, we will send you a decision within 72 hours of receipt of your request. We will notify you by phone if your request does not meet the rules for a fast review. If we notify you by phone, within 3 days we will also send you a letter explaining why we made this decision. The letter also tells you how to file a complaint or grievance if you disagree with our decision to deny your request for a fast review.

Before we will approve certain drugs you may need to try other drugs

In some cases, Brand New Day requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. We call this process "Step Therapy". For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Please refer to the Step Therapy guidance for more information.

You may ask us to make an "exception" to our coverage rules and cover certain prescription drugs

You may ask Brand New Day to make an exception to our formulary coverage rules when:

A drug is not on the Brand New Day formulary.
You want us to waive coverage limits on a drug. For example, for certain drugs, Brand New Day limits the amount of the drug that we will cover. If a drug has a quantity limit, you can ask us to waive the limit and cover more.

Generally, Brand New Day will only approve a request for an exception if the alternative drugs included on the plan's formulary, or additional utilization restrictions would not be as effective in treating a condition and/or would cause adverse medical effects.

The Plan must receive a statement from your physician supporting your request for an exception.

Certain drugs are not covered by Medicare. An exception will not be granted for any drug that is not covered by Medicare.

Who do you call? Where do you send your written request?

You may ask us for to cover a Part D drug by calling Member Services at 1-866-255-4795 (for TTY, call 1-866-321-5955). Please call between the hours of 8:00 a.m. and 8:00 p.m. You may also send your request in writing to us. Whether you call or send a letter, your doctor should complete the form Medicare Part D Coverage Determination Request Form and submit the completed form to us. Completed forms and/or written requests should be faxed to Brand New Day c/o MedImpact at 1-858-790-7100. Or mail the completed form and/or letter to Brand New Day c/o MedImpact, 10680 Treena Street Suite 500, San Diego, CA 92131.

How to ask for a fast review

If we determine your request does not meet the rules for a fast review, we will send you a decision within 72 hours of receipt of your request. We will notify you by phone if your request does not meet the rules for a fast review. If we notify you by phone, within 3 days we will also send you a letter explaining why we made this decision. The letter also tells you how to file a complaint or grievance if you disagree with our decision to deny your request for a fast review.

Who do you call? Where do you send your written request?

To ask for a fast review, call us at 1-866-255-4795 (for TTY, call 1-866-321-5955). You may also send your request in writing to us. Whether you call or send a letter, your doctor should complete the form Medicare Part D Coverage Determination Request Form and submit the completed form to us. Completed forms should be faxed to Brand New Day c/o MedImpact at 1-858-790-7100. Or mail the completed form to Brand New Day c/o MedImpact, 10680 Treena Street Suite 500, San Diego, CA 92131.

How to file an Appeal

If we deny your request for coverage of a prescription drug you can ask us to review our decision. This is called an appeal. Your appeal must be received by Brand New Day within 60 calendar days from the date on the notice of our coverage determination (denial letter).

Where do I send my appeal?

Mail your written appeal to us at Brand New Day, Attention Appeals and Grievances Unit, 1680 E. Hill Street, Signal Hill, CA 90755. Or you can fax your appeal to the Appeals and Grievances Unit: (562) 981-5818.

How long will it take for us to give you a decision?

In general appeals for prescription medication are processed within 7 calendar days of receipt.

How to ask for a fast review of your appeal

If waiting the standard time frame for review of an appeal may seriously harm your health, Brand New Day will expedite review.

Who do you call? Where do you send your written appeal?

To ask for a fast appeal, call us at 1-866-255-4795 (for TTY, call 1-866-321-5955). Please call between 8:00 a.m. and 8:00 p.m. Written requests for a fast appeal should be faxed to the Appeals and Grievances Unit: (562) 981-5818. Or mail the expedited appeal to: Brand New Day, Attention Appeals and Grievances Unit, 1680 E. Hill Street, Signal Hill, CA 90755. Be sure to state "fast" or "expedited" review on the request.

How long will it take for us to give you a decision?

Appeals of Part D coverage determinations that are expedited will be processed within 72 hours of receipt.

How to file a grievance (complaint)

A grievance is a complaint about anything other than a coverage determination. For example if you are unhappy with wait times at a pharmacy, Member Services, cleanliness of a pharmacy, or rude behavior of staff, you can file a grievance.

If you disagree with our decision not to expedite your request for a fast review or we do not provide you with a decision within the required timeframes, you may also file a grievance.

Who do you call? Where do you send your written request?

We encourage you to let us know if you have any questions or concerns about your prescription drug coverage. But, if you wish to file a grievance, call Member Services at 1-866-255-4795 (for TTY, call 1-866-321-5955). Please call between the hours of 8:00 a.m. and 8:00 p.m. Written grievances should be faxed to the Appeals and Grievances Unit at (562) 981-5818. Or mail the grievance to: Brand New Day, Attention Appeals and Grievances Unit, 1680 E. Hill Street, Signal Hill, CA 90755

Appointing a person to act on your behalf

You have the right to ask someone such as a family member or friend to help you with your appeal, grievance, or coverage request. If you have already appointed someone to act on your behalf for health care decisions, please provide a copy of the legal document that names your appointee. We will not be able to release any personal health information to your appointee without your written consent. If you would like to appoint someone to act on your behalf for your appeal, grievance or coverage request, please use the form "Appointment of Representative". Complete the form and return it with your appeal, grievance or coverage request. Please call Member Services if you have a question or concern at 1-866-255-4795 (for TTY, call 1-866-321-5955). Or you may fax your Appointment of Representation form to the Appeals and Grievances Unit: (562) 981-5818. Or mail to: Brand New Day, Attention Appeals and Grievances Unit, 1680 E. Hill Street, Signal Hill, CA 90755.

A complete description of the processes described above can be found in the Evidence of Coverage, Chapter 9, page 113. Click on the following link. Evidence of Coverage.