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: 866-524-4173
Hearing-impaired callers using TTY/TDD equipment: 866-524-4174
8 a.m. to 8 p.m. Eastern 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 it a complaint.
A complaint will be handled as a grievance, coverage determination, or an appeal, depending on the subject.
What is a grievance?
A grievance is any complaint other than one that involves a coverage determination. A grievance would be filed if you had any type of problem with us or one of our network pharmacies that does not relate to coverage for a prescription drug.
For more information on grievances, please see the Evidence of Coverage.
What is a coverage determination?
A coverage determination is the first decision we make about covering the drug you are requesting. If your doctor or pharmacist tells you that a certain prescription drug is not covered, you may contact us if you want to request a coverage determination.
For more information on coverage determinations, please see the Evidence of Coverage.
What is an appeal?
An appeal is any of the procedures that deal 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 ?redermination? if you want us to reconsider and change our decision. If our redetermination decision is unfavorable, you have additional appeal rights.
For more information on appeals, please see the Evidence of Coverage.
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 Evidence of Coverage.
