Coverage Decisions, Appeals, and Grievances

The first time you contact our plan to request that a medical service or Part D prescription drug be covered, you will ask our plan to make a coverage decision.
  • A medical care coverage decision is a decision made by our plan regarding medical care. This includes asking our plan to authorize, provide, or pay for medical services, including the type or level of services, that you believe you should receive.
  • A drug coverage decision is a decision our plan makes about the coverage of or the amount our plan will pay for your Part D prescription drugs. This includes asking our plan to make an exception to the way a drug is covered.
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