What can I do if I have a complaint (also called a grievance) about my plan?
You have the right to file a complaint with the plan.
Some examples of why you might file a complaint include the following:
You believe your plan’s customer service hours of operation should be different.
You have to wait too long for your prescription.
The pharmacy is charging you more than you think you should have to pay. You can file a complaint and ask for a coverage determination.
The company offering your plan is sending you materials that you didn’t ask to get and aren’t related to the drug plan.
The plan doesn’t give you a decision about a coverage determination or redetermination within the required timeframe.
The plan didn’t make a decision about a coverage determination or first-level appeal within the required timeframe and didn’t send your case to the Independent Review Entity (IRE).
You disagree with the plan’s decision not to grant your request for an expedited coverage determination or redetermination.
The plan didn’t provide the required notices.
The plan’s notices don’t follow Medicare rules.
You can file your complaint with the plan over the telephone or in writing. You must file your complaint within 60 calendar days of the date of the event that led to your complaint. Your plan must notify you of its decision generally no later than 30 days after the plan receives the complaint. If the complaint relates to a plan’s refusal to expedite a coverage determination or redetermination and you haven’t yet purchased or received the drug, you must be notified of the decision no later than 24 hours after the plan receives the complaint.
If you think you were charged too much for a prescription, call the company offering your plan to get the most up-to-date price. If the plan doesn’t take care of your complaint, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
Tip: Your State Health Insurance Assistance Program (SHIP) can provide you with free personalized counseling on your prescription drug coverage choices.
(Primary Source: Centers for Medicare and Medicaid Services - Your Guide to Medicare Prescription Drug Coverage 2008. This content may have been enhanced by Q1Group LLC to include further examples, explanations, and links.)
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