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As a member of Vantage Medicare Advantage, you have the right to request a coverage
determination, which includes the right to request an expedited coverage determination,
an exception, the right to file an appeal if we deny coverage for a prescription
drug, and the right to file a grievance.
You have the right to request a coverage determination if you want us to cover a
Part D drug that you believe should be covered. You may ask us for an expedited
(fast) coverage determination or appeal either verbally or in writing if you believe
that waiting for a decision could seriously put your life or health at risk, or
affect your ability to regain maximum function. If your doctor makes or supports
the expedited request, we must expedite our decision.
An exception is a type of coverage determination. You may ask us for an exception
if you believe you need a drug that is not on our list of covered drugs or believe
you should get a non-preferred drug at a lower out-of-pocket cost. You can also
ask for an exception to cost utilization rules, such as a limit on the quantity
of a drug.
If you think you need an exception, you should contact us before you try to fill
your prescription at a pharmacy. Your doctor must provide a statement to support
your exception request. If we deny coverage for your prescription drug(s), you have
the right to appeal and ask us to review our decision.
Finally, you have the right to file a grievance if you have any type of problem
with us or one of our network pharmacies that does not involve coverage for a prescription
drug.
If your problem involves quality of care, you also have the right to file a grievance
with the Quality Improvement Organization (QIO) for your state, Louisiana Health
Care Review, Inc. (225)926-6353 or (800)433-4958.
Complete and submit the correct form below or call:
Phone: (888)823-1910
TTY (866)524-5144 (for the hearing impaired)
Fax: 318-361-2159
Vantage Health Plan, Inc.
130 DeSiard St., Suite 300
Monroe, LA 7120
for general users:
Model Coverage Determination Request Form
for doctors:
Model Coverage Determination Request Form for Physicians
other:
Appointment of Representative Form
for prescriptions:
Medicare Prescription Drug Determination Form
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