Appeals, Grievances and Determinations

What’s important to you is important to us. If you are ever dissatisfied with any aspect of our plans, please contact us and let us know. We have a process in place to make sure we resolve your concerns as quickly as possible.


If we deny your request for coverage, payment or an exception, you have the right to request an appeal.

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If a drug your doctor prescribes is not on our formulary, or if the drug is subject to one of our utilization management requirements, such as step therapy or quantity limits, you or your doctor can request a Formulary Exception. A nonformulary drug that we approve through the Formulary Exception Process will be considered a nonpreferred generic (Tier 2) or nonpreferred brand (Tier 4) drug.

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When we make an “initial decision,” we will explain whether we will provide the prescription drug or medical service you are requesting or pay for one already received.

If you need to request reimbursement for payment, download form (PDF).

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You must have Adobe Reader to download PDF files. Download for free. (You are leaving a Medicare-approved site)


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.

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Your first step

If you have a complaint or a problem, contact us right away. We may be able to resolve your complaint or approve a request over the phone.

You may also refer to Chapter 7 or Chapter 9 in your Evidence of Coverage , titled: What to do if you have a problem or complaint (coverage decisions, appeals, complaints). If you prefer to contact Medicare, you can call (800) Medicare (800-633-4227) or TTY/TDD (877) 486-2048, 24 hours a day, seven days a week. Or you can file a complaint at the Medicare website (You are leaving a Medicare-approved site) . The Office of the Medicare Ombudsman (OMO) (You are leaving a Medicare-approved site) can help you.

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

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