If we say no to your prescription drug coverage request, you can decide if you want to make an appeal.
If we say no, you have the right to request an appeal. Requesting an appeal means asking us to reconsider – and possibly change – the decision we made.
What to do
To start your appeal, you (or your representative or your doctor or other prescriber) must contact us.
If you are asking for a standard appeal, make your appeal by submitting a written request.
If you are asking for a fast appeal, you may make your appeal in writing or you may call us.
Our contact information can be found below.
We must accept any written request, Including a request submitted on the CMS Model Coverage Determination Request Form, which is available on our website.
You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of good cause for missing the deadline may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.
If your health requires it, ask for a “fast appeal”
If you are appealing a decision we made about a drug you have not yet received, you and
your doctor or other prescriber will need to decide if you need a “fast appeal.” If we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it.
Deadlines for a “standard appeal”
If we are using the standard deadlines, we must give you our answer within 7 calendar days after we receive your appeal for a drug you have not received yet.
If we say no to your appeal, you decide if you want to continue with the appeals process and make another appeal.
If we say no to your appeal, we will send a written notice telling you why we said no. You then choose whether to accept this decision or continue by making another appeal. The written notice tells you how to make another appeal. If you decide to make another appeal, it means your appeal is going on to Level 2 of the appeals process. If you decide to go on to a Level 2 Appeal, the Independent Review Organization (Maximus) reviews the decision we made when we said no to your first appeal. Maximus decides whether the decision we made should be changed.
For a full explanation of how to file an appeal about a prescription drug, please see your Evidence of Coverage, Chapter 9, section 6.6.
Pharmacy Department Contact Information
||1-866-255-4795 Ext. 2012; TTY 711
For after hours, please call 1-866-255-4795 Ext. 2010.
|Hours of Operation:
||Monday – Friday 8 a.m. – 6 p.m.
||Brand New Day
Attn: Part D Appeals
P.O. Box 93122
Long Beach, CA 90809
|For more detailed information about filing an appeal, see your Brand New Day Evidence of Coverage on this website or call to request a copy.
Brand New Day is interested in hearing from you about what isn’t working as well as you would like it to. We are interested in complaints you may have about services you received, the way you were treated, the care you received (or didn’t receive in a timely manner), if you were charged incorrectly, or any other complaint you may have. We want to correct any inappropriate behavior, processes, or payments. You will not be "in trouble" or mistreated by us or your doctors if you complain - we are required to treat you fairly.
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