What if you have problems related to coverage or payments for your drugs?
Your Evidence of Coverage
has step-by-step instructions that explain what to do if you have problems related to your drug coverage and costs. Here are the chapters to look for:
- [MA-PD insert: Chapter 7.] [PDP insert: Chapter 5.] Asking the plan to pay its share of a bill you have received for covered services or drugs.
- [MA-PD insert: Chapter 9.] [PDP insert: Chapter 7.] What to do if you have a problem or complaint (coverage decisions, appeals, complaints).
Q1Medicare Note: see: appeals level chart overview
Here are things to keep in mind:
- When we decide whether a drug is covered and how much you pay, it’s called a "coverage decision."
If you disagree with our coverage decision, you can appeal our decision
(see [MA-PD insert: Chapter 9] [PDP insert: Chapter 7] of the Evidence of Coverage).
- Medicare has set the rules for how coverage decision and appeal are handled. These are legal procedures and the deadlines are important. The process can take place if your doctor tells us that your health requires a quick decision.
Please ask for help if you need it. Here’s how:
- You can call us at [insert plan name] Member Services (phone numbers are on the cover of this monthly summary).
- You can call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week.
- You can call your State Health Insurance Assistance Program (SHIP). The name and phone numbers for this organization are in Chapter 2, Section 3 of your Evidence of Coverage.