Generally, you cannot make any other changes during the year unless you qualify for a Special
Election Period. If you wish to leave Freedom Blue PPO, you will need to submit a written and
signed disenrollment request to Freedom Blue PPO. You may also call 1-800-MEDICARE.
Medicare Customer Service Representatives are available 24 hours a day, seven days a week.
TTY/TDD users should call 1-877-486-2048. Until your disenrollment is effective, you must
continue getting your health care through Freedom Blue PPO.
Involuntary Disenrollment
Freedom Blue PPO may end your coverage for any of the following reasons:
• You lose your entitlement to Medicare Part A hospital insurance and / or fail to pay your
Medicare Part B medical insurance
• Freedom Blue PPO is no longer contracting with Medicare or leaves your service area
You permanently move out of the Freedom Blue PPO service area and do not voluntarily
disenroll
• You fail to pay your Freedom Blue PPO premium
• You engage in disruptive behavior, provided fraudulent information when you enrolled or
knowingly permitted abuse or misuse of your enrollment card
• Please consult the Freedom Blue PPO Evidence of Coverage for complete information on
disenrollment rights.
Organization Determination, Coverage Determination, Appeals and Grievances
Organization Determination
As a member of Freedom Blue PPO, you have the right to request an organization determination,
which includes the right to file an appeal if we deny coverage for an item or service, and the right
to file a grievance. You have the right to request an organization determination if you want us to
provide or pay for an item or service that you believe should be covered. If we deny coverage for
your requested item or service, you have the right to appeal and ask us to review our decision.
You may ask us for an expedited (fast) coverage determination or appeal if you believe that
waiting for a decision could seriously put your life or health at risk, or affect your ability to
regain maximum function. If your doctor makes or supports the expedited request, we must
expedite our decision. Finally, you have the right to file a grievance with us if you have any type
of problem with us or one of our network providers that does not involve coverage for an item or
service. If your problem involves quality of care, you also have the right to file a grievance with
the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of
Coverage (EOC) for the QIO contact information.
Coverage Determination
As a member of Freedom Blue PPO, you have the right to request a coverage determination,
which includes the right to request an exception, the right to file an appeal if we deny coverage
for a prescription drug, and the right to file a grievance. You have the right to request a coverage
determination if you want us to cover a Part D drug that you believe should be covered. An
exception is a type of coverage determination. You may ask us for an exception if you believe
you need a drug that is not on our list of covered drugs or believe you should get a non-preferred
drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules,
such as a limit on the quantity of a drug. If you think you need an exception, you should contact