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If you have questions about a ConnectiCare VIP Medicare Plan, contact us toll-free at 1-877-224-8221 between the hours of 8:00 am –8:00 pm, Monday through Friday (TTY/TDD users dial 1-800-842-9710). Extended hours from 11/15–3/1, 8:00 am–8:00 pm, seven days a week.

Grievance Policy and Appeals

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Medication Therapy Management Program
ConnectiCare offers their Beneficiaries the opportunity to participate in a Medication Therapy Management (MTM) Program. The objective of the MTM program is to optimize therapeutic outcomes for Beneficiaries in the treatment of Parkinson's disease and Depression. ConnectiCare Pharmacy Services will promote compliance to medication therapies and increasing communications with health care providers in order to achieve these objectives. Participation in the MTM program is voluntary.

A ConnectiCare Beneficiary will qualify if they meet the following criteria:

Beneficiary is an eligible Medicare Part D enrollee
Beneficiary receives benefits for covered Medicare Part D medications
Beneficiary has received five (5) or more distinct Part D prescription medications
Beneficiary has prescription utilization in the treatment of Parkinson's disease and Depression.
Beneficiary is likely to incur annual prescription costs for covered Medicare Part D medications that exceed $4,000.00 or have aggregate daily prescription costs that exceed $11.00.

Beneficiaries who qualify for the MTM Programs will be enrolled into the MTM program by Pharmacy Services through outreach activities, or alternatively, a Beneficiary may enroll on their own fruition. Once enrolled, the Beneficiary will receive private counseling from a ConnectiCare Clinical Pharmacist on their current medication therapy, and will have access to ConnectiCare's Clinical Pharmacists for future inquiries. ConnectiCare Pharmacy Services will monitor these Beneficiaries for adherence to their medication therapy and consult with the Beneficiary's Healthcare Providers to optimize therapeutic outcomes. The Beneficiary and Healthcare Provider will receive medication compliance reports and the Prescribing Healthcare provider will receive a quarterly poly-pharmacy report.

Inquiries concerning the MTM program or enrollment form may be obtained by calling ConnectiCare Pharmacy Services at 1-800-CCI-CARE.

Potential for Contract Termination
The contracts that ConnectiCare has with the Centers for Medicare & Medicaid Services (CMS) are renewed annually. Availability of coverage beyond the end of the current contract year (2008) is not guaranteed.

Out of Network Medical Services:
In general, Out of Network medical services are not covered in the ConnectiCare VIP Plans unless provided for emergency care, or out of area urgent care or out of area renal (kidney) dialysis, unless approved by the Plan. Members of ConnectiCare VIP Choice Plans have access to any Medicare-approved doctor or hospital in the United States who agrees to accept ConnectiCare's terms and conditions of payment.

Out of Network Prescription Drug Coverage:
Generally, ConnectiCare only covers drugs filled at an out-of-network pharmacy in limited circumstances when a network pharmacy is not available. Covered Part D drugs are available at out of network pharmacies in special circumstances including illness while traveling outside of the plan's service area where there is no network pharmacy. In addition to paying the applicable copayments / coinsurances, you will be required to pay the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out of network pharmacy charged for your prescriptions. Before you fill a prescription at an out-of-network pharmacy, please call Customer Service to see if there is a network pharmacy available.

For Additional Information:
Since there are differences in plan design and covered benefits among the various ConnectiCare Medicare Products, please see the applicable Evidence of Coverage (contract) and Summary of Benefits for more information.

Rx Exceptions and Appeals
ConnectiCare has created an exceptions and appeals resource for the web site to provide individuals with the instructions and the forms they might need for Medicare Prescription Drug exceptions and appeals in one, convenient location.

On this page, you will find instructions for the following items: Coverage Determinations, Prior Authorization, Exceptions, Step Therapy Requirements and Redetermination (Appeals). Formulary Exceptions, Prior Authorization and Step Therapy requests are only applicable to certain medications. If your medication does not appear on the formulary, you may ask for a formulary exception. To find out if Prior Authorization and Step Therapy apply to your medication, please look up your medication on the Medicare formulary search tool and click "Show Notes". If any of these requirements apply to your medication, you will find additional instructions and required forms in this section. You may read more about these items in your Evidence of Coverage (Contract), which is also posted on this site.

Category	Definitions / Instructions	Form should be sent to	Click here for form (as applicable)
Coverage Determinations	Initial coverage determination means the Plan's decision as to whether to provide or pay for a Part D drug including determinations on medical necessity, drugs not on the formulary, drugs furnished by an out-of-network pharmacy, drugs that are benefit exclusions, drugs requested as exceptions, and decisions on cost-sharing amounts. You may contact a ConnectiCare customer Service Advocate concerning your prescriptions or any questions you may have or alternatively, utilized the form provided on the ConnectiCare web site for a Prescription Drug Coverage Determination.	Please send your ConnectiCare Medicare Prescription Drug Coverage Determination form to: FAX: 800-300-9695 or to ConnectiCare Pharmacy Services / Clinical Review, P.O. Box 1520 JAF Station, New York, NY 10116-1520.	See Coverage Determination form
Prior Authorization	ConnectiCare may require a prior authorization for certain medications. This means that your doctor will need to obtain an approval from ConnectiCare before you fill your prescriptions. If your physician does not get prior approval, ConnectiCare may not cover the drug. If you have a situation where your medication is lost or stolen, you may request a prior authorization to address the situation.	Please call ConnectiCare customer Service at 1-800-CCI-CARE between the hours of 8:00 am to 8:00 pm.	Not Applicable
Formulary Exceptions	If your medication is not included in this formulary, you should contact ConnectiCare customer Service and ask if your medication is covered by your benefit. If you learn that ConnectiCare does not cover your drug, you have two options: 1) You can ask customer Service for a list of similar drugs that are covered by ConnectiCare. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by ConnectiCare or; 2) You can ask HIP to make a Prescription Drug Determination.	Please call ConnectiCare customer Service at 1-800-CCI-CARE between the hours of 8:00 am to 8:00 pm.	Please use Medicare Formulary Search tool to see if your medication is on the formulary.
Step Therapy Requirements	Step Therapy Requirements are Protocols where in some cases, ConnectiCare will require you to first try certain medications to treat your medical condition before ConnectiCare will cover another drug. For example, Drug A and Drug B both treat your medical condition. ConnectiCare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, ConnectiCare will then cover Drug B.	Your Physician must send the Certificate of Medical Necessity form to: FAX: 800-300- 9695 or to ConnectiCare Pharmacy Services / Clinical Review, P.O. BOX 1520 JAF Station, New York, NY 10116–1520.	Please use Medicare Formulary Search tool to see if applicable to your medication.
Redetermination (Appeals)	If you have requested one of the above items and your request was not granted, you may appeal this item by following the instructions in your denial letter (either by writing a letter or by using the attached form).	For an Expedited Appeal: You or your appointed representative should contact us by telephone or fax at the numbers below: Phone: 1-866-829-8180 For a Standard Appeal: You or your appointed representative should mail or deliver your written appeal request to the address(es) below: Correspondence: ConnectiCare Grievance & Appeal Department PO Box 2786 JAF Station 10116–2786 Walk-in: ConnectiCare Customer Service 175 Scott Swamp Road Farmington, CT 06032	See Redetermination form.

Instructions on how to appoint a Representative:
Appointment of Representative Form CMS Form (CMS-1696)
Individuals who represent enrollees may either be appointed or authorized. An enrollee may appoint any individual (such as a relative, friend, advocate, an attorney, or any physician) to act as his or her representative and file an appeal on his or her behalf. Also, a representative (surrogate) may be authorized by the court or act in accordance with State law to file an appeal for an enrollee. A surrogate could include, but is not limited to, a court appointed guardian, an individual who has Durable Power of Attorney, or a health care proxy, or a person designated under a health care consent statute. To be appointed by an enrollee, both the enrollee making the appointment and the representative accepting the appointment must sign, date, and complete a representative form (for example, a Form CMS-1696 Appointment of Representative or other conforming instrument). Due in part to the incapacitated or legally incompetent status of an enrollee, a surrogate is not required to produce a representative form. Instead, he or she must produce other appropriate legal papers supporting his or her status as the enrollee's authorized representative.

Either the signed representative form for a representative appointed by an enrollee, or other appropriate legal papers supporting an authorized representative's status, must be included with each appeal. Regarding a representative appointed by an enrollee, unless revoked, an appointment is considered valid for one year from the date that the appointment is signed by both the member and the representative. Also, the representation is valid for the duration of the appeal. A photocopy of the signed representative form must be submitted with future appeals on behalf of the enrollee in order to continue representation. However, the photocopied form is only good for one year after the date of the enrollee's signature. Any appeal received with a photocopied representative form that is more than one year old is invalid to appoint that person as a representative and a new form must be executed by the enrollee.

The following is necessary to complete the approved CMS Form (CMS-1696):

Section I: Appointment of Representative section
The name of the representative is required. In addition, the Medicare Beneficiary must sign and date the form, and complete their address.

Section II: Acceptance of Appointment section
The representative should enter their name in the 1st paragraph, identify their relationship to the beneficiary, sign and date the form, and complete the address / telephone section.

Section III and Section IV should be left blank.
Excerpt from section 60.1.1 of Chapter 13 of the CMS Medicare Managed Care manual effective 03/03/2006.