What To Do if You Have Complaints about Your Part D Prescription Drug Benefits

We encourage you to let Elderplan Member Services know right away if you have questions, concerns or problems related to your prescription drug coverage. We can be reached at 1-800-353-3765, 8 a.m.–8 p.m., 7 days a week (for TTY, call 1-800-662-1220).

This section gives the rules for making complaints in different types of situations. Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan member. 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 we receive a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from Elderplan or penalized in any way if you make a complaint.

A complaint will be handled as a grievance, coverage determination or an appeal, depending on the subject of the complaint.

What is a coverage determination?
What is an appeal?
What is a grievance?

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 preferred 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. For more information, please click on Coverage Determination.

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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. For more information, click on Appeals Process.

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What is a grievance?

A grievance is different from a request for a coverage determination because it usually will not involve coverage or payment for Part D prescription drug benefits. Concerns about our failure to cover or pay for a certain drug should be addressed through the coverage determination process.

What types of problems might lead to you filing a grievance?

• You feel that you are being encouraged to leave (disenroll from) Elderplan.
• Problems with the customer service you receive.
• Problems with how long you have to spend waiting on the phone or in the pharmacy.
• Disrespectful or rude behavior by pharmacists or other staff.
• Cleanliness or condition of pharmacy.
• If you disagree with our decision not to expedite your request for an expedited coverage determination or redetermination.
• You believe our notices and other written materials are difficult to understand.
• Failure to give you a decision within the required timeframe.
• Failure to forward your case to the independent review entity if we do not give you a decision within the required timeframe.
• Failure by Elderplan to provide required notices.
• Failure by Elderplan to provide required notices that comply with the Centers for Medicare & Medicaid Services (CMS) standards.

In certain cases, you have the right to ask for a “fast grievance,” meaning your grievance will be decided within 24 hours.

If you have a grievance, we encourage you to first call Member Services at 1-800-353-3765, 8 a.m.–8 p.m., 7 days a week (for TTY, call 1-800-662-1220). We will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this Elderplan’s Member Grievance Program. We must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

For more information, click on Grievance Process.

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You are entitled to obtain a report about the number of grievances, appeals and exceptions that have been filed with Elderplan. For more information, contact Member Services at 1-800-353-3765, 8 a.m.–8 p.m., 7 days a week (for TTY, call 1-800-662-1220).

More information on coverage determination, grievances and appeals can be found in Sections 4 and 5 of your Elderplan Evidence of Coverage.