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Grievance and Appeals

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. You can also file a written grievance at: 

PO Box 6106 

MS CA124-0157

Cypress, CA 90630

Fax: 1-888-517-7113

Grievance Form

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. You can also request a coverage determination in writing or by fax at:

PO Box 56-6420

Miami, Fl 33256-6420

Fax: 1-866-261-1474

What is an organization determination?

An organization determination is a decision made by the health plan about whether items or services are covered or how much you have to pay for covered items or services. The Medicare Advantage organization's network provider or facility has also made an organization determination when it provides you with an item or service, or refers you to an out-of-network provider for an item or service.  You must contact us if you would like to request an organization determination.  You cannot request an appeal if we have not issued an organization determination.

Please contact the Member Services Department for more information on how to request a coverage of organization determination by Medica Healthcare Plans. You can also request a coverage of organization determination in writing or by fax at:

PO Box 56-6420

Miami, Fl 33256-6420

Fax: 1-866-261-1474

What is an appeal?

An appeal is any of the procedures that deal with the review of an unfavorable coverage determination or organization 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. You may also file an appeal if you want us to reconsider and change a decision we have made about whether items or services are covered or how much you have to pay for covered items or services.  

Please contact the Member Services Department for more information on how to file an appeal with Medica Healthcare Plans. You can file your appeal in writing or by fax at:

PO Box 6106

MS CA124-0157

Cypress, CA 90630

Fax: 1-888-517-7113

Appeal Form

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.

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.           

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.)


Additional Resources:  Member Services Department

Please contact the Member Services Department for information about Appeals, Grievances, Coverage Determinations, or Redeterminations. You can submit your Appeal, Grievance, Coverage Determination, or Redetermination, including oral requests for Expedited Appeals, Coverage Determinations, and Exceptions.  The contact information:

PO Box 56-6420

Miami, Fl 33256-6420

Fax: 1-866-261-1474

Phone: 1-800-407-9069 Monday - Sunday 8:00 am - 8:00 pm

TTY (for the hearing impaired): 711

email: memberservices@uhcsouthflorida.com