Appeals

How to appeal decisions made about your coverage

Sometimes you, your doctor or your pharmacist may ask your plan to cover something it doesn’t already cover. Or you might ask us to cover a service or drug differently or change what we pay for it. When that happens, we have to make what’s called a coverage decision. When we notify you about our decision, you may not agree with it. You can appeal. That’s asking us to review your request again and change our decision. You can always talk to us about an appeal by calling the customer service number on the back of your WyoBlue Advantage ID card.

Here’s an overview of what you need to know about appeals, and other ways to contact us about an appeal when you have a Medicare Advantage plan. You can find more information about appeals in your plan’s Evidence of Coverage.

How long do I have to appeal a decision?

Medicare guidelines give you 65 days to contact us about an appeal after you get our written notification.

Who can appeal a decision?

You or your doctor can start an appeal. A representative—someone other than your doctor acting on your behalf—can also appeal a decision for you, as long as you fill out and send us an Appointment of Representative form.

How long will it take to hear from us about an appeal?

• It depends on what you’re appealing. Appeal time frames will be listed in the initial coverage decision letter that you receive
• If your appeal is related to a medical service you’re waiting to receive, we’ll reply within 30 days
• If your appeal is related to prescription drugs, we’ll reply within seven days
• If your appeal is related to payment for a medical service or drug you’ve already paid for, we’ll reply within 30 days
• If your appeal is related to a medical service you’ve already received, or payment for a medical service you’ve already paid for, we’ll reply within 60 days

What if I can’t wait the standard appeal time frame?

You can ask for a fast appeal when you’re appealing a decision about medical care or a prescription drug you haven’t received yet. If waiting could cause serious harm to your health or hurt your ability to function, you’ll hear from us within 72 hours.

Your doctor should request a fast appeal.

How do I appeal a decision related to a medical service or treatment?

It’s often easiest to call the customer service number on the back of your WyoBlue Advantage card. If you’d rather start your appeal by writing a letter or sending a fax, you’ll find the contact information you need below. The contact information below can also be used to get updates on open appeals.

If you do choose to send in a letter or fax, please describe what you would like to appeal and, if possible, include a copy of the letter you received from us. Include your name, enrollee ID, a daytime telephone number and signature.

WyoBlue Advantage Member Services

1-844-682-9966 TTY: 711

Monday – Friday, 8 am-8 pm from Oct 1 through March 31
Monday – Sunday, 8 am-8 pm, from Apr. 1 thought Sept. 30

Fax: 1-855-636-8299

Mailing Address:
WYBA Appeals and Grievances
PO Box 21012
Eagan, MN 55121

How do I appeal a decision related to prescription drugs?

It’s often easiest to call the Pharmacy Services number on the back of your WyoBlue Advantage ID card. If you’d rather start your appeal by filling out a form, you’ll find the information you need below. The contact information below can also be used to get updates on open appeals.

Pharmacy Benefit Manager for WyoBlue Advantage.

1-855-205-4426
24 hours a day, 7 days a week
Fax: 1-877-852-4070

Mailing Address:
Optum Home Delivery
c/o Appeals Coordinator
PO Box 25184
Santa Ana, CA 92799