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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 DeterminationsAppointment 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 FormsGrievance 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)