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Coverage Determinations, Appeals and Grievances

Your satisfaction is important to us. If you are ever dissatisfied with any aspect of our plans, please let us know. We have a process in place to make sure it’s resolved as quickly as possible.

You have the right to make a complaint if you have concerns or problems related to your coverage or care. If you have a concern, we encourage you to call Client Services. We will try to resolve any complaint that you might have over the phone.

Grievance Process
You have the right to make a complaint if you have concerns or problems related to your coverage or care. 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.

Coverage Determinations
When we make an "initial decision" we will explain whether we will provide the prescription drug you are requesting or pay for one already received.

Appeals
If we deny your request for coverage, payment or for an exception, you have the right to request an appeal, also called a redetermination.

Appointing a Representative
You have the right to appoint someone to act on your behalf and request a coverage determination.

To obtain an aggregate number of grievances, appeals and exceptions filed with the plan, contact us.

 

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