Coverage Determination (Exception), Appeal and Grievance Process

What to do if you have complaints about your Part D prescription drug benefits (appropriate sections from the EOB - forms and instructions below):

Prime Solution
Advantage Solution
Dual Solution

Want to obtain aggregate information regarding the number of exceptions, appeals and grievances?
Please contact Medica Customer Service at 952-992-2300 or 1-800-234-8755.

Coverage Determinations	Appointment of Representative
Including formulary exceptions, prior authorization, step therapy, quantity limits and tiering exception. Forms for your doctor for formulary exceptions Coverage Determination Form Dual Eligible Coverage Determination Form	Appointment of Representative Form
Appeal Process and Forms	Grievance Process and Forms
If your coverage determination is denied, you have the option of filing an appeal. Prime Solutions Appeal Form Advantage Solutions Appeal Form	Prime Solutions Grievance Form Advantage Solutions Grievance Form

Questions? Please call Medica!
952-992-2300 or 1-800-234-8755
TTY 952-992-3650 or 1-800-234-8819

Physician Questions?
1-800-788-2949
Fax 858-578-9732

CMS File #1182(11/2006)