Grievances, Coverage Determinations, Appeals, and Exceptions
We encourage you to call us if you have questions, concerns, or problems related to your prescription drug coverage.
Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan member. Medicare has helped set the rules about what you need to do to make a complaint and what we are required to do when someone makes a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from this plan or penalized in any way if you make a complaint.
A complaint will be handled as a grievance, coverage determination, or an appeal, depending on the subject. To obtain an aggregate number of grievances, appeals, and exceptions filed with us, please contact customer service.
What is a grievance?
A grievance is any complaint other than one that involves a coverage determination. A grievance is filed if you have any type of problem with us or one of our network pharmacies that does not relate to coverage for a prescription drug.
For more information on grievances, please see Chapter 7 in the Evidence of Coverage.
What is a coverage determination?
A coverage determination is the first decision we make about covering the drug you request. If your doctor or pharmacist tells you a certain prescription drug is not covered, you may contact us to request a coverage determination.
For more information on coverage determinations, please see Chapter 7 in the Evidence of Coverage.
What is an appeal?
An appeal is any procedure that deals with the review of an unfavorable coverage determination. You cannot request an appeal if we have not issued a coverage determination. If we issue an unfavorable coverage determination, you may file an appeal called a 'redetermination' if you want us to reconsider and change our decision. If our redetermination decision is unfavorable, you have additional appeal rights.
For more information on appeals, please see Chapter 7 in the Evidence of Coverage.
What is an exception?
An exception is a type of coverage determination. You can ask us to make an exception to our coverage rules for a variety of situations.
For more information on exceptions, please see Chapter 7 in the Evidence of Coverage.
To obtain information on grievances, appeals, and exceptions received by our plan, please contact Customer Service.
To file a grievance or to ask for a coverage determination, appeal, or exception, please contact Customer Service.