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. Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan member.

A complaint will be handled as a grievance, coverage determination, 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 type of complaint you have with SilverScript or one of our network pharmacies that is not considered a coverage determination 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 determination” 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 the type of complaint you make 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 SilverScript reduces or cuts 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.

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

Grievances
Coverage Determination Process
Appeals Process