Determinations, appeals, and grievances
For Medica Prime Solution® (Cost) Members
Do you have a concern?
If you have a concern with your Part D prescription drug coverage or Part C medical benefits, we encourage you to call our Member Services department first. We'll do everything we can to resolve your concern over the phone.
Medica Member Services:
Phone: 1 (800) 234-8755 (TTY: 711), 8 a.m. – 9 p.m. CT
Fax: 952-992-3660
Mail:
Medica
P.O. Box 9310 CP520
Minneapolis, MN 55440
What if your concern isn't resolved?
If we can't resolve your concern over the phone, you may need to take extra steps. These include:
- Determination – a request that we consider coverage
- Appeal – a request that we reconsider a determination
- Grievance – a complaint
Below, we'll walk you through how to complete these next steps.
Coverage Determination for plans that include Part D
A Coverage Determination (Part D) is a request you submit to us that asks us to decide if a Part D drug prescribed for you can be covered by your plan and/or if the amount you are required to pay is appropriate. You can also use this type of determination to ask for us to waive coverage restrictions.
Types of Coverage Determination (Part D) include:
- Formulary exceptions
- Prior authorization exceptions
- Step therapy exceptions
- Quantity limits exceptions
- Tiering exceptions
You can submit a Coverage Determination (Part D) request online or by printing and returning a paper form:
Appeal your determination
If your Coverage Determination request is denied, you have the right to file an appeal asking us to reconsider the initial denial. To start an appeal, you’ll need to submit a Medicare Part D Prescription Drug Denial Appeal form. There are two ways to submit it:
Organization Determination for plans that include Part C
An Organization Determination (Part C) is a request you submit to us that asks us to decide whether a Part C medical service is covered by your plan and/or if the amount you are required to pay is appropriate.
To initiate an Organization Determination (Part C) request, you'll need to contact our Customer Service department via phone, fax or mail (see contact information above).
Appeal your determination
If you submitted a Coverage Determination request and it was denied, you have the right to file an appeal asking us to reconsider the initial denial. To start an appeal, you'll need to download, fill out, and submit a Medica Benefit Review form:
How to file a grievance
- Quality of care
- Waiting times
- Customer service
- Other concerns
Filing a grievance isn’t part of the determination or appeals process; but you can submit a grievance along with a determination request or appeal and it won't affect the outcome.
To submit a grievance, download, fill out, and return our complaint form:
You may also file a grievance directly with Medicare about your Medicare health plan or your Part D prescription coverage online.
How to appoint a representative
You can authorize an someone to act on your behalf. Just download and complete the Appointment of Representative form below. You and your representative will need to sign the form. When it’s complete, submit it along with your determination, appeal, or grievance or send it to the same location where you already sent your determination, appeal, or grievance.
Legal information about appeals and grievances
For detailed information on how to file a grievance, see chapter 9 in your Evidence of Coverage (EOC) document. If you don't have Part D coverage, please see chapter 7 of your EOC document.
To get a total number of grievances, appeals, and exceptions filed with the Plan/Part D Sponsor, contact our Member Services at the number on the back of your member ID card..
Learn more about appeals and grievances on Medicare.gov.
Learn more about drug appeals on Medicare.gov.
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