What is a grievance?
A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with Medica HealthCare Plans, or one of our network pharmacies that does not relate to coverage for a prescription drug. 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 get the information you need, or the cleanliness or condition of a network pharmacy.
Please contact the Member Services Department for more information on how to file a grievance with Medica Healthcare Plans.
What is a coverage determination?
Whenever you ask for a Part D prescription drug benefit, the first step is called requesting a coverage determination. When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exceptions requests. You have the right to ask us for an “exception” if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower co-payment. If you request an exception, your physician must provide a statement to support your request. You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination.
Please contact the Member Services Department for more information on how to request a coverage determination by Medica Healthcare Plans
What is an appeal?
An appeal is any of the procedures that deal with the review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.
Please contact the Member Services Department for more information on how to file an appeal with Medica Healthcare Plans.
Appeals & Grievance Information
If you would like information on the aggregate number of appeals, grievances, and exceptions filed with Medica Healthcare Plans, please contact the Member Services Department.
Medicare Prescription Drug Determination Request Form *** (for use by the member or provider)
Appoint a Representative: If you wish to appoint a representative to file and appeal, reconsideration, or grievance on your behalf, please fill out the CMS Appointment of Representative Form. By doing this, you are also giving us permission to speak with your representative only about the issue in the appeal and/or grievance. The CMS Appointment of Representative Forms can be found here: English Spanish
For More Information, Please See The Evidence of Coverage: The plan EOC’s can be found here. You can find more information on asking for an appeal or a coverage determination in Chapter 9, Section 6 of the EOC. Section 10 of Chapter 9 has more information on filing a Grievance.
Best Available Evidence page on the CMS website
If you think that you have already have been approved for the Low Income Subsidy but you are being charged your full Prescription Drug copayments, you can provide additional information to us in order to correct your records. The Best Available Evidence page on the CMS website gives examples of the information you should provide to us.
(clicking on this link will take you away from the Medica HealthCare Plans website.)
- For use by the member:
- For use by the provider:
Member Services Department
Please contact the Member Services Department for information about Appeals, Grievances, Coverage Determinations, or Redeterminations. You should also contact the Member Services Department if you wish to file and Appeal, Grievance, Coverage Determination, or Redetermination, including oral requests for Expedited Appeals, Coverage Determinations, and Exceptions. The contact information:
Medica HealthCare Plans Member Services Department
4000 Ponce de Leon Blvd. Suite 650
Coral Gables FL 33146
phone: 1-800-407-9069 Monday – Sunday 8:00am – 8:00pm
tty (for the hearing impaired): 1-800-517-6923
Last Update: October 1, 2012 at 6:54 pm