Appeals and Grievances
Complaints, Appeals and Grievances
Your Right to Make Complaints
Your Appeal Rights
Your Right to Make Complaints
You have the right to make a complaint if you have concerns or problems related to your coverage or care. Appeals and grievances are the two different types of complaints you can make.
An appeal is the type of complaint you make when you want First Health Part D (PDP) to reconsider and change a decision we have made about what benefits have been covered for you or what we will pay for a benefit.
A grievance is the type of complaint you make if you have any other type of problem with First Health Part D (PDP) or one of our plan providers.
Refer to your Evidence of Coverage under the section of “Appeals and Grievances” for more detailed information on how to make complaints in different situations.
If you have a complaint, we encourage you to first call Member Services. We will try to resolve any complaint that you might have over the phone or you may send us your grievance and we will respond back to you as quickly as your case requires based on your health status.
If you have complaints about a denial of coverage or payment, you have the right to file an appeal within 60 calendar days after we notify you of the denial.
To file a standard appeal, you can send the appeal to us in writing to:
Medicare Prescription Drug Plan
Attn: Appeals and Grievances
4300 Cox Rd.
Glen Allen, VA 23060
To file a fast appeal, you can call us at (800)-536-6167 Monday-Friday 8 am-5 pm eastern time, (TDD (866) 236-1069).
For additional detailed information, refer to your Evidence of Coverage document, Section “On How to Make an Appeal or Grievance.”
You also have the right to get a summary of information about the appeals, grievances and exceptions that have been filed against First Health Part D (PDP) in the past. To get this information, call Member Services.
Your Appeal Rights
Note: You will also find more information about your appeal rights in your Evidence of Coverage.
There Are Two Kinds of Appeals You Can Request
Expedited (72 hours) - You can request an expedited (fast) appeal for cases that involve coverage if you or your doctor believes that your health could be at risked by waiting up to 7 days for a decision. If your request to expedite an appeal was granted, we must make a decision no later than 72 hours after receiving your appeal.
- If the doctor who prescribed the drug(s) asks for an expedited appeal for you, or supports you in asking for one, and the doctor indicates that waiting for 7 days could seriously harm your health, we will automatically expedite the appeal.
- If you ask for an expedited appeal without support from a doctor, we will decide if your health requires an expedited appeal. If you do not get an expedited appeal, your appeal will be decided within 7 days.
What Do I Include with My Appeal?
You should include your name, address, Member ID number, the reasons for appealing, and any evidence you wish to attach. If your appeal relates to a decision by us not to cover a drug that is not on our list of covered drugs (formulary), your prescribing physician must indicate that all of the drugs on any tier of our formulary would not be as effective to treat your condition as the requested off-formulary drug or would harm your health.
How Do I Request an Appeal?
For an Expedited Appeal: You or your appointed representative should contact us by telephone or fax:
You can call us at (800)-536-6167, TDD 1-800-535-4047, Monday-Friday 8 am-5 pm eastern time.
For a Standard Appeal: You or your appointed representative should mail your written appeal to the address below:
Medicare Prescription Drug Plan
Attn: Appeals Unit
4300 Cox Rd.
Glen Allen, VA 23060
What Happens Next?
If you file an appeal, we will review our original decision. If any of the prescription drugs you requested are denied again, you can appeal to he Independent Review Entity (IRE). If the IRE’s decision is adverse, you have the right to an Administrative Law Judge (ALJ) hearing, if the value of your appeal meets a minimum dollar amount. If you disagree with the ALJ decision, you will have the right to further appeal. You will be notified of your appeal rights if this happens.
Contact Information:
If you need information or help, call Member Services.
Other Resources To Help You:
Medicare Rights Center:
Toll Free: 1-888-HMO-9050
Elder Care Locator
Toll Free: 1-800-677-1116
1-800-MEDICARE (1-800-633-4227)
TTY/TTD: 1-877-486-2048
24 hours a day seven days a week
CMS Approved 1/15/2010
CMS Document ID CMS Document ID: M0003C0002_09MAPDPDP_502_CVTYWEBf