As a Medicare beneficiary, you have the right to file a grievance or an appeal if you are unhappy or dissatisfied with any of the benefits or services you are receiving.
What is a grievance?
Medicare denotes that a grievance is any complaint other than one that involves a request for an initial determination or appeal. Members may file a grievance for such issues as the behavior of a pharmacist or excessive wait times at the pharmacy.
If you wish to file a grievance with Navitus MedicareRx (PDP), you or your designated representative may call Navitus MedicareRx (PDP) Customer Care. They can be reached toll-free at 866-270-3877. Or TTY users please call 711. Customer Care can be reached 24 hours a day/7 days a week, except Thanksgiving and Christmas. You may also submit a grievance in written form.
If your complaint is received by telephone, we will address and resolve your complaint by telephone, especially if your complaint involves a possible misunderstanding or misinformation. If you request a written response, or if your concern is regarding a Quality of Care issue, we will respond in writing to you. The grievance must be submitted within 60 days of the event or incident. We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension or if we justify a need for additional information and the delay is in your best interest.
If you choose to submit your grievance in writing, please send it to:
Navitus MedicareRx (PDP)
Attn: Grievance and Appeals
PO Box 1039
Appleton, WI 54912-1039
Or via Fax: 855-673-6507
What is an appeal?
You can generally appeal our decision not to cover a drug, vaccine, or other Part D benefit. You may also appeal our decision not to reimburse you for a Part D drug that you paid for, or if you think we should have reimbursed you more than you received or you are asked to pay a different cost-sharing amount than you think you are required to pay for a prescription. Finally, if we deny an exception request or you receive an adverse coverage determination, you can appeal.
You need to file your appeal within 60 calendar days from the date included on the specific notification, such as the notice of coverage determination. We can give you more time if you have a good reason for missing the deadline. To file a standard appeal, you or your designated representative may call Navitus MedicareRx (PDP) Customer Care toll-free at 866-270-3877 for an explanation on how to file an appeal. Or TTY users please call 711. Customer Care can be reached 24 hours a day/7 days a week, except Thanksgiving and Christmas. You may also send a signed written appeal to Navitus MedicareRx (PDP), PO Box 1039, Appleton, WI 54912-1039.
When our plan is reviewing your appeal, we take another careful look at all of the information about your coverage request. We check to see if we were being fair and following all the rules when we said no to your request. We may contact you, or your doctor, or other prescriber to get more information. After we receive your appeal, we have up to seven calendar days to give you a decision, but will make it sooner if your health condition requires us to. If we do not give you our decision within seven calendar days, your request will automatically go to the second level of appeal, where an independent organization will review your case.
You, your doctor, or your appointed representative can ask for a fast appeal (rather than a standard appeal) by calling Navitus MedicareRx (PDP) Customer Care. They can be reached toll-free at 866-270-3877. Or TTY users please call 711. Customer Care can be reached 24 hours a day/7 days a week, except Thanksgiving and Christmas.You may deliver a written request to Navitus MedicareRx (PDP) at Navitus MedicareRx (PDP), PO Box 1039, Appleton, WI 54912-1039. You may also fax it to us at 855-673-6507 during or outside our regular business hours. Be sure to ask for a “fast,” "expedited," or “72-hour” review. Remember that if your prescribing doctor provides a written or oral supporting statement explaining that you need the fast appeal process, we will automatically treat you as eligible for a fast appeal.
Please see your Evidence of Coverage for more detailed information concerning the grievance and appeal process.