Coverage determinations, appeals and grievances
If you have concerns or complaints about your prescription drug coverage, you may be able to request a coverage determination or file a complaint. Review the questions below to determine the best way to have your concern addressed. You can also refer to chapter 7 in your Evidence of Coverage to learn more about your options.
Is your concern about your benefits or coverage?Common scenarios include:
- You need to take a drug that isn’t on our drug list
- You would like us to waive a rule or restriction on a drug that is covered on our drug list
- You would like us to cover a drug on our drug list and you believe you meet plan rules or restrictions (such as getting prior authorization) for the drug you need
- You want us to change coverage for a drug to a lower cost-sharing tier
- You would like to be reimbursed for a drug you already received and paid for
- You would like to appeal a determination we have made about your coverage
Is your problem or complaint about your quality of care, waiting times or customer service?
This may include:
- The quality of care you receive at a pharmacy
- The cleanliness of a pharmacy
- Pharmacy wait times
- The quality of customer service you receive from Journey Rx
Get a coverage determination or submit an appeal
Coverage determinations are decisions that we make about coverage or about the amount we will pay for your prescription drugs. Common reasons members request coverage determinations include:
- Getting coverage for a drug that’s not on our drug list (formulary exception)
- Waiving a drug rule that applies to a drug you take or would like to take (prior authorization, quantity limits, step therapy)
- Paying a lower cost-sharing amount for a covered drug that is on a high cost-sharing tier (tier exception)
- Asking us to pay for a drug you already bought (this is a request for a coverage determination about payment)
Request coverage determination
Faxing or mailing coverage determination forms
Use the mailing address or fax number below to submit completed forms for your coverage determination request. You don't have to have all the information complete on the form before submitting, however, all information will need to be completed for a timely decision.
P.O. Box 52000, MC109
Phoenix, AZ 85072-2000
Need to file an appeal to a coverage determination?
Appeals are sometimes called redeterminations and it is your right to file an appeal to a coverage determination. There are 5 levels of appeals that you can make if any part of a request for a coverage determination is denied. Instructions about how to file an appeal are in the coverage determination letter you should have received. If you have questions or concerns or want to check the status of an appeal, call 1-844-232-2330 (TTY: 711), 24 hours a day, 7 days a week.
File a grievance
If you have complaints or disputes (other than a coverage determination or late enrollment penalty determination) about any part of Journey Rx operations, activities or behavior, you can file a grievance about your experience. A grievance may also include a complaint that Journey Rx refused to expedite a coverage decision or appeal as initially requested.
Examples of grievances include, but aren’t limited to:
- Waiting times
- Quality of care
- Access to, and/or setting of a provided item
You can file a complaint by calling or writing customer service using the contact information below, or directly with Medicare by calling 1-800-MEDICARE (1-800-633-4227), or by using the Medicare online complaint form.
Complaints can be sent to:
P.O. Box 3834
Scranton, PA 18505
Contact customer service
If your question isn’t addressed on this page or if you have questions about the information available, please contact our customer service team. You may a request an aggregated number of grievances, exceptions or appeals filed with the plan.
Appoint a representative
You may choose someone to act on your behalf in filing a grievance and requesting a coverage determination or redetermination. If you have questions, contact customer service.
Acceptable Forms of Authorization Documentation:
- Power of Attorney (POA) documentation.
- Document showing surrogate appointed by a court or authorized under State or other applicable law. Note: A surrogate could include, but is not limited to, a court-appointed guardian, an individual who has Durable Power of Attorney or a health care proxy, or a person designated under a health care consent statute.
- The CMS-1696 Appointment of Representative form. Note: A completed AOR form is valid for one year from the date of signature.
- Equivalent Written Notice of the CMS-1696 AOR form; which includes your contact information, your plan ID or Health Insurance Claim Number (HICN)1, contact information of the individual being appointed, authorization statement and acceptance of authorization, your signature/date and signature/date of individual being appointed. Note: The Equivalent Written Notice is valid for one year from the date of signature.
1HICN is being replaced by the Medicare Beneficiary ID (MBI) starting in April 2018.