Review

An Applicant or Member, or his or her designee, may seek Review of a Plan decision. An Applicant or Member may be assisted by his or her designee. Prescription Advantage will not provide review of any determination made by a Medicare Part D Plan, and members of those plans must seek review through those plans. Review consists of the following: (1) Customer Service. The Plan shall maintain a customer service center accessible toll-free by telephone (including TTY services) to assist Applicants and Members to resolve any issue regarding the Plan. Said customer service center shall comply with applicable federal and state law regarding communication accessibility. Contacting Customer Service is not a required step in seeking review of a Plan decision. (2) Reconsideration. (a) An Applicant or Member, or his or her designee, may request Reconsideration of a decision made by the Plan to deny or terminate enrollment, the Plan's determination of a Member's Gross Annual Household Income, or a decision by the Plan to deny or limit Covered Benefits. A request for Reconsideration is the first step in the review process. Such requests must be made in writing to the Plan. (b) When an Applicant or Member, or his or her designee, requests Reconsideration of a decision made by the Plan to deny enrollment in the Plan pursuant to 651 CMR 15.06(6), or to terminate enrollment in the Plan pursuant to 651 CMR 15.13, such request must be made in writing and be received by the Plan within 15 Business Days after the Applicant's or Member's receipt of such decisions rendered by the Plan. (c) Upon receipt of an Applicant's or a Member's request for Reconsideration pursuant to 651 CMR 15.15(2)(a) or (b), a designated Plan representative shall review the Applicant's or Member's enrollment file and attempt to resolve any outstanding issues. (d) The designated Plan representative shall make a determination regarding an Applicant's or Member's request for Reconsideration according to applicable statutes, regulations and/or Plan policies. (e) Within 15 Business Days after receiving a request for Reconsideration, the Plan shall mail to the Applicant or Member, or his or her designee, a written notice setting forth the Reconsideration determination, including the regulatory and/or legal citations and policy basis supporting the determination and a Member's right to an Administrative Review, if applicable. (3) Administrative Review. (a) Overview. 1. A Member, an Applicant, or his or her designee, may seek an Administrative Review of an adverse Reconsideration determination. Such determinations include, but are not limited to: a. a denial of a Member's request to obtain a Non-preferred Drug at the Copayment level of a Preferred Drug; b. a denial of a Member's request to add to the Plan Formulary a Prescription Drug excluded from the Plan Formulary; c. a denial of a Member's request to gain access to a Prescription Drug excluded from the Plan Formulary at Plan Formulary rates. 2. A Member, an Applicant, or his or her designee, may seek an Administrative Review only after pursuing Reconsideration pursuant to 651 CMR 15.15(2). 3. To preserve the right to an Administrative Review, a Member or Applicant, or his or her designee, must respond to the Plan in writing within 15 Business Days after the Plan's written notification of its Reconsideration finding is received by the Member. 4. The Administrative Review shall be conducted by an Administrative Review Officer. An Administrative Review Officer shall: a. have no prior involvement in any matter related to the Member's or Applicant's issue under Administrative Review; and b. have no direct or indirect financial interest, personal involvement or bias in any matter related to the Member's or Applicant's issue under Administrative Review. (b) Administrative Review Process. 1. Unless a Member or Applicant requests that a determination be made on the written record as submitted, the Administrative Review Officer shall schedule an Administrative Review meeting. The Member or Applicant, or his or her designee, may attend the Administrative Review meeting in person or by telephone. The Member or Applicant, or his or her designee, may present any oral or written information to support his or her request. The Plan shall also be permitted to appear at the meeting in person or by telephone and present any oral and written information in support of its decision. 2. An Administrative Review meeting ordinarily will be scheduled no later than 30 Business Days after receipt of a request for an Administrative Review. 3. Information. a. The Plan and Members or Applicants must submit to the Administrative Review Officer all materials supporting their position no later than the conclusion of the scheduled Administrative Review. b. In the case of a request for Administrative Review according to 651 CMR 15.15(3)(a)1.a., such information must include, but not be limited to: i. written certification issued by the Member's physician that the Non-preferred Drug is medically necessary and that there is no therapeutically equivalent Preferred Drug or Generic Drug available to the Member on the Plan Formulary; and, ii. documentation satisfactory to the Administrative Review Officer exhibiting that the Co-payment for the Non-preferred Drug would create a financial hardship to the Member. c. In the case of a request for Administrative Review according to 651 CMR 15.15(3)(a)1.b. or c., such information must include, but not be limited to: i. a written certification issued by the Member's physician that the Prescription Drug excluded from the Plan Formulary is medically necessary and that there is no therapeutically equivalent Prescription Drug available to the Member on the Plan Formulary; and, ii. documentation satisfactory to the Administrative Review Officer exhibiting that payment for such drug would create a financial hardship to the Member. d. The Administrative Review Officer may, in his or her discretion, find that additional information is required prior to rendering a determination, including but not limited to written and verbal information. In such cases, the Administrative Review Officer shall inform the Plan and/or the Member or Applicant, or his or her designee, that they have no more than ten Business Days to submit applicable written information to the Administrative Review Officer. The Administrative Review Officer shall forward such additional information to the non-submitting party and allow five Business Days for that party to respond. e. Members or Applicants who fail to comply with the information requirements of 651 CMR 15.15(3)(b)3. in a timely manner may be subject to an adverse determination. 4. Determination. a. The Administrative Review Officer shall examine the information provided during the Administrative Review process and render a final written determination. Said determination shall be made in accordance with applicable statutes, regulations, and policies governing the Plan. The written determination shall set forth the legal, regulatory and/or policy basis for such determination, and the action, if any, to be taken by the Plan. b. The Administrative Review Officer shall mail the written determination, to the Member or Applicant, or his or her designee, and the Plan within 20 Business Days of the receipt of the last submitted information from the Member or Applicant or the Plan.