Medicare Part D coverage determinations and complaints (Appeals & Grievances).


Coverage determinations and exceptions

This section describes how you can exercise your right to request a Coverage Determination under your Bright Health Medicare Advantage plan. A coverage determination is any decision made by the Part D plan sponsor regarding;

  1. Your receipt of, or payment for, a prescription drug that you believe may be covered;
  2. A tiering or formulary exception request;
  3. The amount that Bright Health requires you to pay for a Part D prescription drug and you disagree with the amount;
  4. A limit on the quantity (or dose) of a requested drug and you disagree with the requirement or dosage limitation;
  5. A requirement that you try another drug before Bright Health will pay for the requested drug and you disagree with the requirement; and
  6. A decision whether you have, or have not, satisfied a prior authorization or other utilization management requirement.

To find a pharmacy near you, please click here. To find out if your prescriptions are covered under your plan, please click here.

Please enter your zip code at the top of the page so we can provide you with the most accurate process and contact information

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Last Updated: Fri Nov 23 2018

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Bright Health plans are HMOs and PPOs with a Medicare contract. Our plans are issued through Bright Health Insurance Company or one of its affiliates. Enrollment in our plans depends on contract renewal.

This information is not a complete description of benefits. Call 844-667-5502 | TTY:711 for more information.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

You must continue to pay your Medicare Part B premium.

Every year, Medicare evaluates plans based on a 5-star rating system.

Medicare beneficiaries may also enroll in Bright Health Medicare Advantage plans through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov 

Bright Health Medicare Advantage plans are plans with a network of doctors, hospitals, pharmacies, and other providers. Out-of-network/noncontracted providers are under no obligation to treat Bright Health members, except in emergency situations.

Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs.

Other providers are available in our network. Most network providers participate through our Care Partner.

Bright Advantage Special Care (HMO SNP) has been approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) through 2021 based on a review of Bright Advantage Special Care (HMO SNP) Model of Care.

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