Grievances, Appeals and Exceptions Information
"Appeals" and "grievances" are the two different types of complaints you can make. A general overview of our policies is provided. For information on our Grievance and Appeals Process, please see the section of your Evidence of Coverage (EOC) document titled "What to Do If You Have a Problem or Complaint (Coverage Decisions, Appeals, Complaints)". This section of your EOC document explains how to ask for coverage decisions and make appeals if you are having trouble getting the prescription drugs you think are covered by our plan. This includes asking us to make exceptions to the rules or extra restrictions on your coverage for prescription drugs, and asking us to keep covering hospital care and certain types of medical services if you think your coverage is ending too soon. The EOC document also explains how to make complaints about quality of care, waiting times, customer service, and other concerns.
Submitting a Grievance
Current members who wish to file a written grievance should submit their information to
Grievances & Appeals. You can call the telephone number registered for receiving oral grievances, or you send a written grievance to the mailing address and fax number listed for your plan.
To obtain an aggregate number of grievances, appeals and exceptions filed or for full information on benefits, please call
Customer Care.
If you decide to switch to premium withhold or move from premium withhold to direct bill, it could take up to three months for it take effect and you will ultimately be held responsible for those premiums.
We Listen to Your Concerns
We do our best to give you all the information you need to make the most of your benefits, and we listen to any concerns. You have the right to make a complaint if you have concerns or problems related to your prescription drug coverage or the service you receive.
We have procedures to help ensure that appeals and grievances are answered in a timely manner. More information about these procedures is available in our member materials for our prescription drug plan (PDPs) and Medicare Advantage prescription drug (MAPD) plans (which you can view on the Documents tab once you select a plan). You should also know that we have developed procedures to monitor the quality of your service, which are listed on the Documents tab under Quality Assurance Procedures.
Contract Renewal
Our prescription drug plan (PDPs) and Medicare Advantage prescription drug (MAPD) plans have a Medicare contract. Since contracts with Medicare are renewed annually, both the Prescription Drug Plans and the Medicare Advantage prescription drug (MAPD) plans cannot guarantee availability of coverage beyond the end of their current contract year.
If our Medicare contract is terminated or if we stop offering PDP or MAPD benefits, we will give you written notice of when that change will be effective. We will also provide you with information about alternative Prescription Drug Plans or Medicare Advantage prescription drug (MAPD) plans in your area, and the steps you need to take to continue your prescription drug coverage with Medicare. At that time, you would be eligible for a Special Enrollment Period, and could choose a new PDP sponsor or MAPD sponsor without being subject to a late enrollment penalty.
Contract Termination Procedures
All Medicare Prescription Drug Plans and Medicare Advantage prescription drug (MAPD) plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Prescription Drug Plan or Medicare Advantage prescription drug (MAPD) plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 60 days before your coverage will end. The letter will explain your options for Medicare prescription drug coverage in your area.
Forms for Enrollees:
Prescription Drug Information:
- Conditions and Limitations: By law, certain types of drugs or categories of drugs are not covered by Medicare Prescription Drug Plan sponsors. These drugs or categories of drugs are called "exclusions". Please note that excluded drugs cannot be requested as an exception.
- Out of Network Prescription Drug Coverage: Review the procedures for filling prescriptions outside of the network
How do I request an exception to the formulary?
Contact Information for Process or Status Questions
If you are an enrollee or physician, please use the following contact numbers for process or status questions:
Customer Care.
You may be able to get extra help to pay for your prescription drug premiums and costs.
For more information about receiving extra help to pay for your prescription drug coverage, select a plan and review the LIS (Low Income Subsidy) Premium Summary Chart.
To see if you qualify for getting extra help, you may also call:
- 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7days a week), or
- The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call, 1-800-325-0778, or
- Your State Medicaid Office.
*In certain cases, CMS systems do not reflect a beneficiary's correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan. In order to address these special situations, CMS has created the Best Available Evidence (BAE) policy. This policy requires Part D plans to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary's information is not accurate. For more information about this CMS policy,
click here
Materials may be available in alternative formats.
If you have qualified for additional assistance for your Medicare Prescription Drug Plan costs, the amount of your premium and cost at the pharmacy will be less. Once you have enrolled in a (PDP) plan, Medicare will tell us how much assistance you are receiving, and we will send you information on the amount you will pay. If you are not receiving this additional assistance, you should contact 1-800-MEDICARE (TTY/TTD users call 877-486-2048), your state Medicaid Office, or local Social Security Administration Office to see if you might qualify.