PrimeWest Senior Health Complete (HMO SNP)

• Our online search feature lets you see if specific Part D drugs are covered by PrimeWest Senior Health Complete (HMO SNP).
• Our Formulary lists the Part D drugs covered by PrimeWest Senior Health Complete (HMO SNP).
• The list of Medicaid-covered, Part D-excluded drugs tells you which drugs are covered under your Medical Assistance benefit.
• Our Over-the-Counter drug list tells you which of these drugs are covered by PrimeWest Senior Health Complete (HMO SNP). The items on the list are covered when you have a prescription from your health care provider or pharmacist.

Read about drug restrictions in Chapter 5, Section 5 of your Evidence of Coverage

Read Chapter 5, Section 6 of your Evidence of Coverage to find out what you can do if your drug is not covered. This includes instructions for both new and current members.

• Read about "coverage decisions" and "Appeals" in Chapter 9, Section 6 of your Evidence of Coverage.
• You may use the Secure Online Submission Process to ask for a coverage decision or appeal.
• We encourage you to contact PrimeWest Health Member Services first if you have a Grievance. However, you can also tell Medicare about your Grievance directly by visiting the Centers for Medicare & Medicaid Services (CMS) website.

Yes, someone you name may file a complaint (Grievance) or Appeal for you. The person you name would be your "appointed representative." You may name a relative, friend, lawyer, advocate, health care provider, or anyone else to act for you. Other people may already be authorized by the Court or under State law to act for you. If you want someone to act for you who is not already authorized by the Court or State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. You may call Member Services to learn how to name your appointed representative. You may also fill out the Appointment of Representative form. Once you have filled out the form, you may print and fax the form to 1-800-693-6703 (toll free). Or, you can mail it to the following address:

Prime Therapeutics LLC
Clinical Review Dept
1305 Corporate Center Drive
Eagan, Minnesota 55121

• Use the Formulary Exception Form. Note: this form must be completed by a health care provider. Completed forms can be mailed or faxed to:
  
  Mail:   Prime Therapeutics LLC
           Attn: Medicare Appeals Dept
           1305 Corporate Center Dr, Bldg EC
           Eagan, MN 55121
  Fax:    1-800-693-6703 (toll free)
  
  
• You may also contact Member Services at 1-800-366-2906 (toll free) 7 days a week, 8 a.m. – 8 p.m. TTY users should call 1-800-627-3529 or 711 (toll free). If you contact us, we may need to get more information from your prescribing health care provider. If you need help or have questions, call Member Services.
  
• You may also use the Secure Online Submission Process to ask for an exception.

• Read your Provider/Pharmacy Directory for a list of Minnesota pharmacies in the PrimeWest Senior Health Complete (HMO SNP) network.
• Use our online search feature to see if a specific pharmacy is in the PrimeWest Senior Health Complete (HMO SNP) network.

You may call Member Services about your Grievance or Appeal at 1-800-366-2906 (toll free), 7 days a week, 8 a.m. – 8 p.m. TTY users call 1-800-627-3529 or 711 (toll free). You may also send a fax to 1-877-600-4912 (toll free).

You may send a letter about your Grievance or Appeal to PrimeWest Health at the following address:

        PrimeWest Health Appeals & Grievances
        2209 Jefferson St, Ste 101
        Alexandria, MN 56308

You may call the Ombudsman for State Managed Care Programs at the Minnesota Department of Human Services about your Grievance or Appeal or to request a State Fair Hearing at 1-800-657-3729 (toll free) or 1-651-431-2660.

You may send a written request for a State Fair Hearing to the following address:

        Minnesota Department of Human Services
        Appeals Office
        PO Box 64941
        Saint Paul, MN 55164-0941

To file an Appeal about your Medicare Part D benefits, you may call Member Services about your Grievance or Appeal at 1-800-366-2906 (toll free), 7 days a week, 8 a.m. – 8 p.m. TTY users call 1-800-627-3529 or 711 (toll free). You may also send a fax to 1-800-693-6703 (toll free).

What is a Grievance?
A Grievance is any complaint, other than one that involves a request for an initial determination or an Appeal. Grievances do not involve problems related to approving or paying for medical care, services, Part D or non-Part D drugs, problems about having to leave the hospital too soon, and problems about having Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF) services ending too soon.

What types of problems might lead you to file a Grievance?

• Problems with the service you receive from Member Services
• You feel that you are being encouraged to leave (disenroll from) the Plan
• We don't give you required notices
• You believe our notices and other written materials are hard to understand
• Waiting too long for prescriptions to be filled
• Waiting too long on the phone, in the waiting room, or in the exam room
• Problems getting appointments when you need them or waiting too long for them
• Rude behavior by network pharmacists or other staff
• Cleanliness or condition of network pharmacies
• We fail to respect your rights
• You disagree with our decision not to give you a "fast" decision or a "fast" Appeal
• We don't give you a decision within the required time frame

If you have one of these types of problems and want to make a complaint, it is called "filing a Grievance."

Who may file a Grievance
You or someone you name may file a Grievance. The person you name would be your "appointed representative." You may name a relative, friend, lawyer, advocate, health care provider, or anyone else to act for you. Other people may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. To learn how to name a representative, you may call Member Services at 1-800-366-2906 (toll free).

Filing a Grievance with our Plan
If you have a complaint, you or your representative may call Member Services at
1-800-366-2906 (toll free). We will try to resolve your complaint over the phone. We will give you a decision within 10 days. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. If you ask for a written response, file a written Grievance, or your complaint is related to quality of care, we will respond in writing to you.

If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this the written Grievance process. You can send us a letter about your Grievance. Write to:

       PrimeWest Health Appeals & Grievances
       2209 Jefferson St, Ste 101
       Alexandria, MN 56308

We will notify you within 10 days that the Grievance has been received. The Grievance must be submitted within 60 days if the complaint is regarding Part D drugs. We must address your Grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. We will tell you within 30 days that we are taking extra time and the reasons why. If we deny your Grievance in whole or in part, our written decision will explain why we denied it and will tell you about any dispute resolution options you may have.

For quality of care problems, if you have Medicare, you may also complain to the Quality Improvement Organization (QIO)
You may complain about the quality of care received under Medicare, including care during a hospital stay. You may complain to us using the Grievance process, the Quality Improvement Organization (QIO), or both. In Minnesota, the QIO is called Stratis Health. You may contact Stratis Health at 1-800-444-3423 (toll free) or 1-952-854-3306 (Twin Cities Metro) or write to:

       Stratis Health
       2901 Metro Dr, Ste 400
       Bloomington, MN 55425

Fast Grievances
You have the right to ask for a "fast" or "expedited" Grievance. You may file a fast or expedited Grievance orally or in writing. We will respond to your oral or written Grievance within 24 hours.

Filing a complaint with the Centers for Medicare & Medicaid Services (CMS)
We encourage you to contact PrimeWest Health Member Services first if you have a Grievance. However, you can also tell Medicare about your Grievance directly by visiting the Centers for Medicare & Medicaid Services (CMS) website.

PrimeWest Health Appeals & Grievances
2209 Jefferson St, Ste 101
Alexandria, MN 56308

Yes. You may submit a complaint online through the Centers for Medicare & Medicaid Services website.