Appeals, Grievances, Coverage Determinations and Exceptions
As a member of MediGold, you have the right to request an appeal, file a grievance and ask for a coverage determination and a formulary exception. For status or process questions or to obtain an aggregate number of grievances, appeals and exceptions filed with the plan, please call Member Services at 1-800-240-3851 (TTY 711)1-800-240-3851 (TTY 711), 8 a.m. - 8 p.m., 7 days a week. You may also refer to your Evidence of Coverage for complete details.
An appeal is a request you may make for reconsideration of our determination on a service, supply or drug you have received or requested. You may file an appeal when you believe that the services or supplies should be covered or that they should be covered differently than MediGold approved or paid them. Your doctor can also request an appeal for you.
A grievance is a complaint that does not involve a coverage determination. For example, grievances may be filed if you are unhappy with the quality of care or service you receive from us or from our providers. You also have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug.
24 hours a day, 7 days a week
CVS Caremark Medicare Part D Grievance Department
P.O. Box 30016
Pittsburgh, PA 15222-0330
A coverage determination is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist. You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.
We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can request an appeal. Your doctor can also request a coverage determination for you.
You may ask us for a formulary exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to utilization management restrictions, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision.
Appoint a Representative
To appoint a representative to act on your behalf, you may download this form or call Member Services for assistance.
CMS Appointment of Representative Form (By clicking the link, you will be leaving the MediGold website.)
You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or appeal a decision.
File a Complaint with Medicare
You can also submit a complaint about your Medicare health plan or prescription drug plan directly to Medicare using the Medicare Complaint Form (by clicking the link, you will be leaving the MediGold website) or you may call 1-800-MEDICARE (1-800-633-42271-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-20481-877-486-2048.