Grievances & Appeal Policies

We encourage you to let us know right away if you have questions, concerns, or problems related to your prescription drug coverage. We hope that if you have a problem or concern, you will try an informal approach first by calling Customer Care. Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care. If you need help from an independent government organization, please call: your State Health Insurance Assistance Program or Medicare at 1-800-MEDICARE (1-800-633-4227, 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. You can also visit www.Medicare.gov.

A complaint will be handled as a grievance, coverage decision, or an appeal, depending on the subject of the complaint.
The Medicare program 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. You cannot be disenrolled from this Plan or penalized in any way if you make a complaint.

A “grievance” is a complaint you have with SilverScript Insurance or one of the network pharmacies. A grievance is not considered a coverage decision or appeal issue. For example, you would file a grievance if you have a problem with things such as waiting times when you fill a prescription, the way your network pharmacist or others behave, being able to reach someone by phone or getting the information you need, or the cleanliness or condition of a network pharmacy.

A “coverage decision” occurs if your pharmacist tells you that we will not cover a drug which you believe should be covered, or he/she tells you that the drug is covered at a higher cost than you think you are required to pay. You have the right to request a decision called a “coverage determination” from us.

An “appeal” is a complaint when you want us to reconsider and change a decision we have made about what prescription drug benefits are covered for you or what we will pay for a prescription drug. For example, if we refuse to cover or pay for a prescription drug you think we should cover, you can file an appeal. If we reduce or cut back on the prescription drugs you have been receiving, you can file an appeal. If you think we are stopping your prescription drug coverage too soon, you can file an appeal.

As a member of our plan, you have the right to get several kinds of information from us in a way that works for you. For Information about our plan including information about the plan's financial condition please contact Customer Care. It also includes information about the number of appeals made by members and the plan's performance ratings, including how it has been rated by plan members and how it compares to other Medicare prescription drug plans.

For specific details on how to file a complaint, please click on the appropriate link below based on the above definitions.

Grievances
Coverage Determination Process
Appeals Process
Medicare Prescription Drug Plan Ratings