A Healthy CollaborationSM

Appeals and Grievances

What are appeals and grievances?

PrescribaRx members have the right to make a complaint regarding concerns or problems related to coverage or care. "Appeals" and "grievances" are the two different types of complaints that can be filed.

A "grievance" is the type of complaint a member can make if the member has any other type of problem with PrescribaRx or one of our network pharmacies. For example, a member should file a grievance if the member has problems with things such as waiting times when filling a prescription, the way the network pharmacist or others behave, being able to reach someone by phone or getting the needed information, or the cleanliness or condition of a network pharmacy.

An "appeal" is the type of complaint a member can make when the member wants PrescribaRx to reconsider and change a decision we have made about what prescription drug benefits are covered or what we will pay for a prescription drug. For example, if we refuse to cover or pay for a prescription drug a member thinks we should cover, an appeal can be filed.  

Appeals

Here are some examples of situations where a member may want to file an appeal:

  • If a member is not getting a prescription drug the member believes may be covered by PrescribaRx.
  • If a member receives a Part D prescription drug that the member believes may be covered by PrescribaRx, but we have refused to pay for it.
  • If we will not provide or pay for a Part D prescription drug that a member’s doctor has prescribed because it is not on our list of covered drugs (called a "formulary"). A member can request an exception to our formulary.
  • If the member disagrees with the amount that we require to pay for a Part D prescription drug a member’s doctor has prescribed. A member can request an exception to the co-payment we require to pay for a drug.
  • A member requests an exception to our formulary or to the co-payment for a drug and we denied the request.
  • If a member is being told that coverage for a Part D prescription drug will be reduced or stopped.
  • If there is a requirement that a member try another drug before we pay for the drug the member’s doctor prescribed, or if there is a limit on the quantity (or dose) of the drug and the member disagrees with the requirement or dosage limitation.
  • A member bought a drug at a pharmacy that is not in our network and the member wants to request reimbursement for the expense.
  • We do not make a decision on a member’s request within the required time frame.


Please Note: If we approve an exception request for a non-formulary drug, the member cannot request an exception to the co-payment we require to pay for the drug.

How do I file my appeal?
To file a standard appeal, you can send the appeal request to us in writing or by phone at:

PHONE   1-866-316-6049
TTY 1-866-684-5351
FAX  1-866-868-0858
MAIL   PrescribaRx
Attn: Appeals
P.O. Box 391197
Solon, OH 44139-3911

To file an expedited appeal, call the phone number above and ask for an expedited appeal.

What is the deadline for submitting an appeal?
You must file your appeal within 60 days of the date on the letter that is attached to the coverage determination notification. If you happen to miss the 60-day deadline, we may grant you an extension on a case-by-case basis.

How quickly will PrescribaRx respond after my appeal is submitted?
Standard appeals must be completed within seven days of receiving your appeal request. Expedited appeals must be completed within 72 hours of receiving your appeal request.

What happens if my appeal is denied?
If we deny all or part of your appeal request, you or your appointed representative may request a review by an independent review entity (IRE). The IRE is contracted directly with the federal government and is not affiliated with PrescribaRx. Please refer to your Evidence of Coverage, section on Appeals, for more information on what to do next.

Grievances

Here are some examples of situations where a member may want to file a grievance:

  • Problems with the service you receive from customer service
  • If you feel that you are being encouraged to disenroll from PrescribaRx
  • If you disagree with the decision not to give you a "fast" decision or a "fast" appeal
  • 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
  • Problems with the cleanliness or condition of the pharmacy
  • You believe our notices and other written materials are difficult to understand
  • Failure of PrescribaRx to make a decision within the required time frame
  • Failure of PrescribaRx to forward your case to the independent review entity if we do not make a decision within the required time frame

Filing a grievance with PrescribaRx
If you have a grievance, we encourage you to first call Member Services at 1-800-818-0007 (TTY: 1-800-958-2692) from 8 AM to 8 PM, 7 days a week.

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 to you in writing. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this the PrescribaRx Grievance Process.

You may file a grievance by telephone, fax, or through the mail, no later than 60 days after the event that caused the grievance. When you file a written grievance you will receive a written confirmation that your grievance was received. In certain cases such as urgent medication refills or life threatening situations, you have the right to ask for a "fast" grievance, meaning we will answer your grievance within 24-48 hours do not file a "fast" grievance by mail, as we cannot guarantee a response within 24-48 hours.

The plan will review the grievance and take corrective action as necessary. A grievance does not involve an appeal or coverage determination. 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 time frame 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.

Please refer to your Evidence of Coverage, section on Grievances, for more information on what to do next.

PrescribaRx Part D Grievances
CALL 1-800-818-0007
TTY   1-800-958-2692
FAX   1-800-216-5876
MAIL PrescribaRx – Grievance Department, Part D
P.O. Box 13187
Pensacola, FL 32591

You are entitled to obtain an aggregate number of grievances, appeals, and exceptions filed with PrescribaRx. You may do so by filing a written request to PrescribaRx – Grievance Department, PO Box 13187, Pensacola, FL 32591.

Appoint a Representative

You can name a relative, friend, advocate, attorney, doctor, or someone else to act on your behalf as your representative. The Centers for Medicare & Medicaid Services (CMS) requires written notification from both the member and the representative. Print the Appointment of Representative form.

 

S5597_S5825_C0008_09P0043_v2 (09/2009) Last updated: 09/09/2022

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