Grievances

Grievances involving prescription drugs are those that involve complaints other than coverage determinations. For example, a Member may file a grievance if they have a problem with things such as waiting times when filling a prescription, the way a network pharmacist behaves, or not being able to reach someone by phone or get information. Part D grievances are handled as quickly as the Member's case requires based on their health status, but no later than thirty (30) calendar days after receiving the complaint. Expedited Grievances can be filed, requiring VISTA to make a decision within twenty-four (24) hours of receipt of the request. A Member, his/her appointed representative, or Provider may file a grievance in writing, by completing the Grievance Form and mailing it to: VISTA Grievances and Appeals Department 1340 Concord Terrace Sunrise, FL 33323 Or via fax by faxing the grievance to: (954) 858-3437 The grievance may also be filed in person with the Grievances and Appeals Department at the address noted above. The grievance may also be filed orally by calling VISTA's Customer Service Department, 7 days per week, 8:00 AM - 8:00 PM. VISTA Members 1-866-847-8235 VISTA South Florida Members 1-800-441-5501 TDD 1-888-444-7352 for speech or hearing impaired

Coverage Determinations

Coverage Determinations involve making a decision whether or not to provide or pay for a Part D drug and what the Member's share of the cost is for the drug. Coverage determinations include exception requests. The Member has a right to request an "exception" if they believe they need a drug that is not on the health plan's formulary or they believe they should get a drug at a lower Co-Payment. All requests for exceptions must be supported by a statement by the prescribing physician. Standard coverage determinations will be made by VISTA within seventy-two (72) hours and Fast Coverage determinations will be made by VISTA within twenty-four (24) hours. A Member, his/her appointed representative, or Provider may request a coverage determination, including a tiering or formulary exception by completing the Request for Medicare Part D Coverage Determination Form and mailing it to: VISTA Pharmacy Department 1340 Concord Terrace Sunrise, FL 33323 Or via fax by faxing the form to: (954)858-3386 The Coverage Determination Request may also be filed orally by calling VISTA's Pharmacy Customer Service Department, 7 days per week, 8:00 AM - 8:00 PM. VISTA Members 1-800-977-7339 VISTA South Florida Members 1-800-842-7442 TDD 1-888-444-7352 for speech or hearing impaired

Appeals/Redeterminations

Appeals are filed when the Member wants the health plan to reconsider and change a decision that has been made about what Part D prescription drug benefits are covered or the Member's cost sharing portion. Appeals are handled as quickly as the member's case requires, based on their health status, but no later than seven (7) calendar days after receiving the request for reconsideration. An Expedited Appeal will be handled within seventy-two (72) hours. VISTA cannot extend the timeframe for handling a Standard or Expedited Part D Appeal. If VISTA's Reconsideration decision upholds the Initial Determination in whole or part, the Member may forward their case to a CMS contractor for an independent review in accordance with federal law. The CMS contractor will inform the Member and VISTA, of its decision. If the CMS contractor upholds VISTA's decision, the Member will be informed of further rights to administrative and judicial review. A Member, his/her legal or appointed representative, or Provider must file an appeal by completing the Appeal/Redetermination Form, and mailing it to: VISTA Grievances and Appeals Department 1340 Concord Terrace Sunrise, FL 33323 Or via fax by faxing the appeal to: (954) 858-3437 The appeal may also be filed in person with the Grievances and Appeals Department at the address noted above. The appeal/redetermination may also be filed orally by calling VISTA's Customer Service Department, 7 days per week, 8:00 AM - 8:00 PM. VISTA Members 1-866-847-8235 VISTA South Florida Members 1-800-441-5501 TDD 1-888-444-7352 for speech or hearing impaired The request must be filed within sixty (60) calendar days of the date of notice of the adverse Initial Determination. Extensions, however, may be granted upon request if VISTA determines that good cause exists. The appeal may be filed directly with VISTA, with the Social Security Administration or, when applicable, the Railroad Retirement Board. The Social Security Administration or Railroad Retirement Board will forward these requests to VISTA. If a Member wishes to act through an authorized representative, an "Authorization for Release of Protected Health Information" form must be signed by the Member, appointing another party to act on behalf of the Member.

Forms

See form for completion and submission instructions Grievance Form Request for Medicare Prescription Drug Coverage Determination Appeal/Redetermination Form Non-Formulary/Prior Authorization Request Appointment of Representative

Customer Service

If you or your physician have questions about the grievance, coverage determination, or appeals processes or would like to inquire about the status of a coverage determination or appeal request, please contact VISTA Customer Service, 7 days per week, 8:00 AM - 8:00 PM. VISTA Members: 1-866-847-8235 VISTA South Provider Members: 1-800-441-5501 TDD 1-888-444-7352 for speech or hearing impaired

Evidence of Coverage (EOC)

For further information about VISTA's Grievances, Coverage Determination, and Appeals Processes, please refer to your Evidence of Coverage. To view, click here, choose the Plan you are enrolled in, and then click on Evidence of Coverage.