Grievances, Coverage Determinations, Appeals, and Exceptions

We encourage you to call us if you have questions, concerns, or problems related to your prescription drug coverage.

TEAMStar Medicare Part D Customer Service

  • Toll-free: 1-866-524-4173
  • Hearing-impaired callers using TTY/TDD equipment: 1-866-524-4174
  • 8 a.m. to 8 p.m. in your local time zone

Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan member. Medicare has helped set the rules about what you need to do to make a complaint and what we are required to do when someone makes a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from this Plan or penalized in any way if you make a complaint.

A complaint will be handled as a grievance, coverage determination, or an appeal, depending on the subject. To obtain an aggregate number of grievances, appeals, and exceptions filed with us, please contact Customer Service.

What is a grievance?

A grievance is any complaint other than one that involves a coverage determination. A grievance is filed if you have any type of problem with us or one of our network pharmacies that does not relate to coverage for a prescription drug.

To file a grievance only, contact Customer Service.

What is a coverage determination?

A coverage determination is the first decision we make about covering the drug you request. If your doctor or pharmacist tells you that a certain prescription drug is not covered, you may contact us to request a coverage determination.

What is an appeal?

An appeal is any procedure that deals with the review of an unfavorable coverage determination. You cannot request an appeal if we have not issued a coverage determination. If we issue an unfavorable coverage determination, you may file an appeal called a 'redetermination' if you want us to reconsider and change our decision. If our redetermination decision is unfavorable, you have additional appeal rights.

To begin the process of an appeal online, you can email OptumRx using the email address below. When sending your message, please include:

  • Your Name and Member ID
  • The Case Number/Decision you are appealing
  • The Name and Phone Number of your Prescriber

DO NOT include your Medicare ID number, SSN, or the name of the medication that you are appealing. We will gather this information if necessary in future communications.

Email for Appeals:

What is an exception?

An exception is a type of coverage determination. You can ask us to make an exception to our coverage rules for a variety of situations.

For more information on exceptions, please see the Chapter 7 in Evidence of Coverage. To obtain information on grievances, appeals, and exceptions received by our Plan, please contact Customer Service.

To ask for a Coverage Determination, Exception, or to file an Appeal, contact OptumRx directly at 1-855-828-8951.

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