Medicare Advantage: Part D Prescription Drug Coverage Determinations, Grievances and Appeals

Part D Prescription Drug Coverage

Coverage Determinations

When we make an “initial decision,” we will explain whether we will provide the prescription drug you are requesting or pay for a prescription drug you have already received. This is called a “Coverage Determination.” If our initial decision is to deny your request (which is also called an adverse coverage determination), you can “appeal” the decision by requesting a “redetermination.”
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Appeals, or Redeterminations

If we deny your request for coverage, payment or for an exception, you have the right to request an appeal, also called a redetermination. Appeals are the type of complaint you make when you want us to reconsider and change an initial coverage decision.
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Grievances

You have the right to make a complaint if you have concerns or problems related to your coverage or care. If you have a grievance, we encourage you to first call Client Services. We will try to resolve any complaint that you might have over the phone. An example of a grievance would be having a problem with things such as waiting times when you fill a prescription, the way your plan pharmacist or others behave, or the cleanliness of a plan pharmacy.
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H2312_H2322_2 September 9, 2006