Who May Request an Appeal?
You, your prescriber or your representative may request a standard or expedited (fast) appeal. You can name a relative, friend, advocate, attorney, doctor or someone else as your representative. Others may already be authorized under state law to be your representative.
To learn how to appoint a representative, please call us at 1-866-901-8000 (TTY 1-877-454-8477).
What Kind of Appeal Can I Request?
There are two kinds of appeals you can request: standard and expedited.
1Standard (seven days)
You, your prescriber or your representative can request a standard appeal. Jefferson Health Plans must give you a decision no later than seven days after we receive your appeal.
You, your prescriber or your representative can request an expedited (fast) appeal if you or your prescriber believe that your health could be seriously harmed by waiting up to seven days for a decision. You cannot request an expedited appeal if you are asking us to pay you back for a prescription drug you already received. If your request to expedite is granted, Jefferson Health Plans must give you a decision no later than 72 hours (three days) after we get your appeal.
If your prescriber requests an expedited appeal for you, or supports you in asking for one, and indicates that waiting for seven days could seriously harm your health, we will automatically expedite your appeal.
What Do I Include with My Appeal Request?
You should include your name, address, member number, the reasons for appeal and any evidence you wish to attach. If your appeal relates to a decision by Jefferson Health Plans to deny a drug that is not on our formulary, your prescriber must indicate that all the drugs on any tier of our formulary would not be as effective to treat your condition as the requested off-formulary drug or would harm your health.
How Do I Request an Appeal?
To request a standard or expedited appeal, you, your prescriber, or your representative should contact Jefferson Health Plans by phone at 1-866-901-8000 (TTY 1-877-454-8477) or by fax at 215-991-4105.
You can also submit your appeal request online.
You, your prescriber, or your representative can also mail or deliver your written appeal request to the address below:
Attn: Complaints, Grievances & Appeals Unit
1101 Market Street, Suite 3000
Philadelphia, PA 19107
What Happens Next?
If you request an appeal, Jefferson Health Plans will review your case and give you a decision. If any of the prescription drugs you requested are still denied, you can request an independent review of your case by a reviewer outside of your Medicare drug plan. If you disagree with that decision, you will have the right to further appeal. You will be notified of your appeal rights if this happens.