Plan information

Appeals and grievances

Appeals

If we told you that we will not cover or pay for a medical or pharmacy service and you do not agree with our decision, you can appeal it. An appeal is a formal way of asking us to review and reconsider our decision.

When you file an appeal, we review our original decision to see if we were following the rules properly. Different reviewers than those who made the original decision will handle your appeal. When we have completed the review, we will give you our decision. You need to file an appeal within 60 calendar days of the date listed on the notice of the initial coverage decision.

To appeal a decision about a drug claim

You or your appointed representative can complete the Request for Redetermination of Medicare Prescription Drug Denial Form and submit it to us.

 

To appeal a decision about medical services

You or your appointed representative can contact us in one of the following ways to file an appeal:

  • Call Member Services at 1-855-833-8128 (TTY: 711)
  • Fax your appeal letter with your reason for appealing to 617-897-0805
  • Send your appeal letter to:
    WellSense Medicare Advantage
    Attn: Member Appeals
    529 Main Street 5th Floor
    Charlestown, MA 02129

If you disagree with the appeal decision, you can make another appeal. To learn more about the appeals process, please see your Evidence of Coverage, which has detailed instructions on how to file appeals.

If you need help making an appeal, you have options.

  • Call Member Services at 1-855-833-8128 (TTY 711) and our agents can walk you through the appeal process
  • Your doctor can make a request for you
  • Ask someone to act on your behalf

Grievances

If you are dissatisfied with your experience with a doctor, pharmacy or staff member of our plan or if you disagree with a decision we have made, you can file a grievance.

A grievance is a way for you to file a formal complaint if you are dissatisfied with any aspect of the quality of care or services you receive from a doctor, staff member, pharmacy or our plan. You can file a grievance if you disagree with a coverage decision we made about a medical service or drug. You can file a grievance if you requested an expedited appeal decision but we reviewed it as a standard appeal.

A grievance will not change the outcome of a coverage decision or a payment dispute, but your expression of dissatisfaction will remain on file with us and allow us to use your concerns when updating processes and policies.

How to file a grievance

You or your appointed representative can file a grievance in the following ways.

  • Call Member Services at 1-855-833-8128 (TTY: 711)
  • Send a fax to 617-897-0805
  • Send a letter to:
    WellSense Medicare Advantage
    Attn: Member Grievances
    529 Main Street 5th Floor
    Charlestown, MA 02129

You can also submit your complaint directly to Medicare. You can use their online form or you can call 1-800-MEDICARE (1-800-633-4227) to speak with a representative. TTY/TDD users can call 1-877-486-2048. These lines are open 24 hours per day, seven days a week.

Aggregate number of appeals, grievances and exceptions

You can request the aggregate number of appeals, grievances and exceptions by calling Member Services at 1-855-833-8128 (TTY: 711)

Appointment of a representative

If you want a friend, relative, your doctor or another person to represent you in your healthcare-related affairs, you can give person permission to submit coverage determinations, exceptions and appeals on your behalf. Complete the Appointment of Representative (AOR) form and be sure you and the person who will act on your behalf sign it. You must provide us a copy of the signed form.

An AOR form is valid for 365 days from the date both parties signed the document. Once you submit a valid AOR, the form will be on file with us until it expires. You can ask us to reuse an AOR on file with each new appeal or grievance request. You can also revoke a request for appointment of a representative by completing a revocation form and providing that to us.

Appointment or Revocation of a Representative form

Coverage determinations

Some drugs may have restrictions or require approval before you can get them

There may be restrictions on certain drugs in our drug list. These drugs have special rules that must be followed before you can get them. For example, your doctor may need to prove that a certain drug is necessary for your health before a drug will be covered. It is your right to request that we cover a drug that we do not typically cover or cover a drug that has restrictions. Your provider can help you request a coverage decision, also called a coverage determination, and provide reasons why he/she thinks you need the drug.

How to request a coverage decision

To request approval for a drug that is not covered or restricted, you, your doctor or an appointed representative can submit a Request for Drug Coverage Determination. This form can be submitted to us in one of the following ways:

  • Mail to: Express Scripts
    Attn: Medicare Reviews
    P.O. Box 66571
    St. Louis, MO 63166-6571
  • Fax to: (877) 251-5896
  • Call Express Scripts: (877) 417-1828

What Happens Next?

We will review your request and then make a coverage determination, which is a decision about whether we will cover the drug you requested and the amount, if any, that you are required to pay for the drug. We will notify you of our decision within 72 hours from when we received your request. If your doctor agrees that waiting 72 hours will harm your health, you or your doctor can ask us for a faster decision. If you submit the request, your doctor must also call or write us to confirm the need. We will then give a decision within 24 hours.

If your request is not approved, you have the right to appeal our decision.

Drug utilization

How we ensure the safe use of prescriptions

We use a number of pharmacy programs to promote the safe and correct use of certain drugs. Drugs that belong to these programs have medical policies that must be met before we cover them. Here’s a summary of our pharmacy programs.

Prior Authorization Program (PA)


Some drugs require your doctor or nurse to get prior approval, or prior authorization, from us before you can fill a prescription. If a drug falls into this group and may be medically necessary for you, your doctor can submit a request to us to cover your prescription, or you can submit a request yourself.

Step Therapy Program (ST)

Step therapy requires that you try certain covered drugs before we will cover another similar drug. If you and your doctor feel that a covered drug is not appropriate to treat your medical condition, your doctor can submit a prior approval request.

Quantity Limitation Program (QL)

This program ensures the safe and appropriate use of some drugs. We may put limits on the amount of a drug that can be given by the pharmacist at one time. If your doctor feels that a greater amount is medically necessary for you, he or she can submit a prior approval request.

Specialty Pharmacy Program (SP)

This program requires some drugs to be supplied by a specialty pharmacy. These drugs include oral, injectable and intravenous drugs that are often used to treat chronic (ongoing) conditions and require the additional expertise and support of a specialty pharmacy. We contract with certain specialty pharmacies to provide these drugs.

Enrollment

How to enroll

Enrolling in a WellSense Medicare Advantage plan is easy. We offer several different ways to enroll. You choose what makes sense for you.

  • Apply online
  • Download, print and mail your application to:
  • WellSense Health Plan Medicare Advantage
    P.O. Box 106101
    Jefferson City, MO 65110-9808
  • Or fax your completed form to (866) 266-0802
  • Call us at (800) 967-4497 (TTY: 711) to help you enroll over the phone
  • Medicare beneficiaries can also enroll in a WellSense Medicare Advantage plan through the Centers for Medicare & Medicaid Services (CMS) Medicare Online Enrollment Center at medicare.gov

Disenrollment

You can end your membership in the WellSense Medicare Advantage plan during certain times of the year, typically during the Annual Enrollment Period (AEP) that runs from Oct. 15 to Dec. 7 or during the Open Enrollment Period (OEP) from Jan. 1 to March 31. In certain circumstances, you may be able to leave the plan at other times of the year, during Special Enrollment Periods (SEP).

During an enrollment period, if you choose to end your membership in our plan, you can enroll in another Medicare plan. If you want to switch from our plan to Original Medicare without a Medicare prescription drug plan, you must request to be disenrolled from our plan. If you would like to be disenrolled you can make the request by writing to us at:

WellSense Medicare Advantage
ATTN: Enrollment
529 Main Street 5th Floor
Charlestown, MA 02129

Most cases of disenrollment are your choice but, in some circumstances, you may be disenrolled involuntarily. There are situations that could require you to leave our plan, such as:

  • Loss of your Part A benefits and/or disenrollment in Part B
  • Failure to pay your plan premium

Disenrollment from our plan is subject to CMS rules. For more information about disenrolling from our plan or your rights and responsibilities, see your Evidence of Coverage.

You can call Member Services at 1-855-833-8128 (TTY: 711) if you have questions about disenrollment. You can also contact Medicare directly at 1-800-MEDICARE (1-800-633-4227) to disenroll.

Medicare Advantage prescription drug transition policy

As a new member you may currently be taking drugs that are not on our drug list, or they are on our drug list but your ability to get them is limited. Under certain circumstances, we can offer a temporary supply of a drug to you when your drug is not on the drug list (formulary) or when it is restricted in some way.

If you are a new member and you do not live in a long-term care facility:

For each of your drugs that is not on the formulary or if your ability to get your drugs is limited we cover an initial 30-day transition supply of the drug anytime during the first 90 days you are a plan member. If the prescription is written for less than 30 days, multiple fills are allowed to provide up to a total of 30 days of the drug.

If you are a new member and are a resident in a long-term care facility:

If you live in a long-term care (LTC) facility and are currently taking a drug that is not on the formulary or your ability to get the drug is limited, we will cover a temporary 31-day transition supply. If you need a drug that is not on the formulary or your ability to get your drug is limited, but you are past the first 90 days of plan membership, we will cover a one-time emergency supply of up to 31 days to allow you time to discuss alternative treatment with your doctor or to request a formulary exception.

The transition fill will give you time to talk to your doctor and find another medication that will work for you. There may be a similar drug that works just as well, or a generic version of the same drug that has the same active ingredient. If after talking with your doctor, there are no appropriate alternatives on the formulary, you or your doctor can ask us to make an exception and cover that drug. Your doctor will have to give reasons why he/she thinks that you need to take a certain medication.

Medication therapy management

What is the Medication Therapy Medication (MTM) program?

We understand that keeping track of multiple medications and dosing schedules can be difficult. That is why as a member of WellSense Medicare Advantage (HMO), you can have a specially trained clinical staff such as a pharmacist or nurse review all your medications with you. These clinicians can help answer any of your questions and work with your doctor to make sure your medications are appropriate, safe, and effective. The MTM Program is not considered a benefit and is a free service for eligible members.

Who is eligible?

Members are automatically enrolled quarterly into the MTM program if they meet ALL of the following criteria:
2022 criteria

  1. You have at least two (2) of the following chronic conditions:
    • Asthma
    • Bone Disease – Arthritis, Osteoporosis
    • Chronic Heart Failure (CHF)
    • Chronic Obstructive Pulmonary Disease (COPD)
    • Chronic Noncancer Pain
    • Diabetes
    • Depression
    • Dyslipidemia
    • Hypertension
  2. You are taking at least eight (8) or more different covered Medicare Part D medications that are considered chronic or maintenance drugs
  3. You have an accumulated drug cost (not what you pay) of $1,174 in the previous quarter for covered Medicare Part D medications

What is a comprehensive medication review?

The Comprehensive Medication Review (CMR) is done with you over the phone and will give you the opportunity to review all of your current medications with a pharmacist or other qualified clinician. This is a one-on-one, conversation by phone that takes about 30 minutes. After completing the CMR, you will be mailed a personal medication list (PML) and a medication action plan (MAP). The PML will include your current prescription medications, over-the-counter medications and dietary and herbal supplements. The MAP will summarize what you and the pharmacist or other qualified clinician discussed during the CMR and discussion topics for you and your doctor.

We will also conduct ongoing Targeted Medication Reviews (TMRs) and your doctor may be contacted by mail if we identify any issues with your medications.

To help you track your medications, you can also download a blank Personal Medication List for your personal use.

Members may also receive helpful information in the mail. This can include additional information about their medications and suggestions from our pharmacists or other qualified clinicians about how to make the most of your medications and benefits. This information can be helpful when meeting with your doctor or pharmacist.

For more information

We encourage you to take full advantage of this service. If you do not want to take part in the program, or if you have questions, please contact Member Services.

To view the PDF files above, you may need to download a free copy of Adobe® Acrobat Reader* software on your computer.

*When you click on this link, you will leave our website.

Member services

Contact Member Services at (855) 833-8128 (TTY: 711) Monday through Friday 8 a.m. to 8 p.m. (April 1 through September 30, except holidays) or seven days a week (October 1 through March 31).