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FAQ
 

Exceptions, Appeals, Grievances

  What is a Formulary Exception?
An exception is a coverage determination request, to cover a prescription that is not on the list of covered drugs, or to change the conditions related to using a drug.

Reasons for requesting a formulary exception:

  You need a drug that is not on the CareAdvantage list of covered drugs (formulary).
  A drug that you have been using that used to be covered has been removed from the list of covered drugs for 2008.
  You need a drug that your doctor has prescribed without being required to try another drug first.
  The number of pills your doctor has prescribed is higher than the limit covered by the plan.
  You think a prior authorization requirement for a drug your doctor has prescribed should be waived based on your condition.

  What is an Appeal?
An appeal is a type of request you can make to ask us to rethink and change our decision to not pay or cover a service. If HPSM does not approve your formulary exception, you need to ask us within 60 days from the date of the notice of denial you receive from us.

  What is a Grievance?
A grievance is a complaint you can make if you have problems or are not satisfied with the quality of service you receive from a doctor’s office or the HPSM.

  Who Can I Contact for General Information on Complaints about HPSM?
Call the CareAdvantage Unit at 1-866-880-0606 or (650) 616-2174
Monday through Sunday, 8 a.m. to 8 p.m.
TTY: 1-800-735-2929 or dial 711


© Health Plan of San Mateo