Clear Care PPO Medicare Advantage Part D Drug Formulary

This formulary is a list of drugs selected by Group Health Options Inc., — and approved by the Centers for Medicare and Medicaid Services (CMS) — that are covered by Group Health's Clear Care prescription drug plans. Based on consultation with a team of health care providers, these prescription therapies are believed to be a necessary part of a quality treatment program.

•	2010 Clear Care Part D Comprehensive Formulary (PDF)
•	2010 Clear Care Part D Abridged Formulary (PDF)

Please note: Group Health requires prior authorization or quantity limits for certain drugs. Here is the prior authorization drug list (PDF), and the quantity limit drug list (PDF) for 2010.

If a drug isn't covered
If your doctor or pharmacist says that a certain prescription drug is not covered, call Customer Service to ask why the drug was not covered. Here are other steps you can take:

Exceptions, Appeals, and Grievances

Exceptions to the Formulary
You can ask us to cover a non-formulary drug, or to waive coverage restrictions or limits on a drug. For example, for certain drugs, Group Health limits the amount of the drug that we will cover. If the prescribed drug has a quantity limit, you can ask us to waive the limit and cover more.

A formulary exception may be requested by you or your appointed representative (see details below) and the prescribing physician. A request can be submitted by phone, fax, or mail.

Once Group Health receives the physician's statement, the decision-making time period begins. Group Health will have 72 hours (for a standard request) or 24 hours (for an expedited request) to notify you of our decision. The request will be expedited if your doctor tells Group Health that your life or health will be seriously jeopardized by waiting for a standard response.

How to Request an Appeal
If Group Health denies a request for coverage of a drug, you have the right to request an appeal. You must request this appeal within 60 days from the date of the coverage determination.

An appeal may be requested by a patient or an authorized representative (see details below) and the prescribing physician. Please include: Member name, address, member ID number, reasons for requesting an exception, and any evidence you wish to attach. A request for an appeal redetermination may be submitted by fax, mail, or in person.

Fax
206-901-7340

Mail
Group Health Cooperative
Group Health Member Appeals Department
Attn.: Appeals Coordinator
P.O. Box 34593
Seattle, WA 98124-1593

In person
12400 E. Marginal Way S.
Seattle, WA 98168-2559

Once Group Health receives the request for an appeal, we have seven days (for a standard request for coverage or for a request to pay the member back) or 72 hours (for an expedited request for coverage) to notify the member of our decision. The member's request will be expedited if a physician confirms that your life or health will be seriously jeopardized by waiting for a standard decision.

For information on the status of your appeal redetermination request, please contact the Group Health Appeals department at 206-901-7359 or toll-free 1-866-458-5479.

Filing a Grievance
A grievance is any complaint or dispute regarding an organization's or a provider's operations, activities, or behavior. Grievances do not include denial or discontinuation of health care services, or denial of claims.

To file a grievance, contact Group Health Customer Service at 1-888-901-4600 toll-free or send a fax to 206-901-6205. You can also contact us by mail:

Group Health Cooperative
Customer Service
P.O. Box 34590
Seattle, WA 98124-1590

Grievances must be filed no later than 60 days after the incident in question.

Group Health will review the complaint and respond as quickly as the case requires, but no later than 30 days after the grievance is received. A 14-day extension is allowed if you request it, or if Group Health needs time to gather more information and can show that the delay is in your interest. Group Health must notify you of the delay in writing.

Authorized Representatives
You can ask anyone you want to help you with your Medicare prescription drug plan. If this person agrees to help you in this way, she or he is your authorized representative. Your authorized representative can be someone appointed to make decisions for you, such as a guardian or health care proxy, or attorney-in-fact.

If someone else will be filing a grievance or requesting an exception or an appeal on your behalf, please complete the following form and submit along with other supporting documentation.

Clear Care PPO Service Area:

Yakima, Franklin, Benton
In these counties, coverage is available in every ZIP code.

Jefferson and Clallam
In Jefferson County, coverage is available in these ZIP codes only: 98325, 98339, 98358, and 98368. In Clallam County, coverage is available in these ZIP codes only: 98362, 98363, and 98382.

MEDICARE ADVANTAGE PLANS INDEX

CMS Review #: M0063_H2810_MK10WEB20110
Page last updated: Jan. 12, 2010