Prescription Drug Plans Plan Complaints, Grievances, and Appeals

What to do if you have complaints

We encourage you to let us know right away if you have questions, concerns, or problems related to your prescription drug coverage. Please call our Customer Service at 1-800-688-1604 (TTY/TDD: 1-800-716-3231) 24 hours a day, seven days a week. Calls to these numbers are free.

Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan customer. The Medicare program has helped set the rules about what you need to do to make a complaint and what we are required to do when someone makes a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from this Plan or penalized in any way if you make a complaint.

A complaint will be handled as a grievance, coverage determination, or an appeal, depending on the subject of the complaint. The other sections on this page briefly discuss grievances, coverage determinations, and appeals.

For Quality of Care Complaints, You May Also Complain to the Quality Improvement Organization (QIO)

For Wisconsin, the Quality Improvement Organization (QIO) is Livanta. Complaints concerning the quality of care received under Medicare may be acted upon by the Medicare prescription drug plan under the grievance process, by an independent organization called the QIO, or by both. For example, if an enrollee believes his/her pharmacist provided the incorrect dose of a prescription, the enrollee may file a complaint with the QIO in addition to or in lieu of a complaint filed under the Part D plan's grievance process. For any complaint filed with the QIO, the Part D plan must cooperate with the QIO in resolving the complaint.

How to File a Quality of Care Complaint with the QIO

Quality of care complaints filed with the QIO must be made in writing. An enrollee who files a quality of care grievance with a QIO is not required to file the grievance within a specific time period. To file a quality of care complaint with the QIO you can contact Livanta using the information below.

Livanta
10820 Guilford Rd., Suite 202
Annapolis Junction, MD 20701

  1-888-524-9900 (TTY:1-888-985-8775)
   Fax: 1-888-236-2423
 Livanta website

Filing a Complaint with Medicare

You can file a complaint directly with Medicare. You can call 1-800-Medicare (1-800-633-4227) 24 hours a day, seven days a week. TTY/TDD users can call 1-877-486-2048. Calls to these numbers are free.

If you wish to file a complaint without calling, please follow the instructions in the link below.
Medicare Complaint form

What is a Grievance?

A grievance is any complaint or dispute, other than a coverage determination or an LEP determination, expressing dissatisfaction with any aspect of the operations, activities, or behavior of a Part D plan sponsor, regardless of whether remedial action is requested. A grievance may also include a complaint that a Part D plan sponsor refused to expedite a coverage determination or redetermination. Grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided item.

You would file a grievance if you have any type of problem with us or one of our network pharmacies that does not relate to coverage for a prescription drug. For example, you might file a grievance if you have a problem with things such as waiting times when you fill a prescription, the way your network pharmacist or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of a network pharmacy.

How to File a Grievance

A grievance usually will not involve coverage or payment for Part D prescription drug benefits (concerns about our failure to cover or pay for a certain drug should be addressed through the coverage determination process found under the Coverage Determinations tab listed above).

In certain cases, you have the right to ask for a "fast grievance," meaning your grievance will be decided within 24 hours. We discuss these fast-track grievances in more detail under asking for a fast decision on the Coverage Determinations tab listed above.

If you have a grievance, we encourage you to first call Customer Service. We will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this the WPS Complaints and Grievances procedure. WPS Complaints and Grievances addresses concerns about the service you have received. For example, you may file a service grievance if you are dissatisfied about the way a staff person has handled your particular issue or with the care you received from your pharmacy.

You may file a service grievance by calling Customer Service at 1-800-688-1604 (TTY 1-800-716-3231) 24 hours a day, seven days a week, or by submitting a service complaint and grievance in writing to:

WPS MedicareRx Plan
c/o Express Scripts
ATTN: Service Grievance Resolution Team
P.O. Box 3610
Dublin, OH 43016-0307
Fax: 1-614-907-8547

Whether you call or write, you should contact Member Services right away because a grievance must be filed with WPS no later than 60 days after the event or incident that brought about the grievance.

The Plan may contact you by phone to resolve your service grievance. If your service grievance is not resolved in five days, you will receive a written acknowledgement that your grievance has been received. If your grievance involves a decision by our Appeals department to deny your request to "expedite" a coverage determination or redetermination, we will respond to you within 24 hours of receipt of your grievance, provided that you have not already purchased or received the drug that is in dispute. We must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. We may extend the time frame by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

What is a Coverage Determination?

Whenever you ask for a Part D prescription drug benefit, the first step is called "requesting a coverage determination." When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exception requests. You have the right to ask us for an "exception" if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower copayment. If you request an exception, your doctor must provide a statement to support your request. You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination.

How to Request a Coverage Determination

We use the word "provide" in a general way to include such things as authorizing prescription drugs, paying for prescription drugs, or continuing to provide a Part D prescription drug that you have been getting.

If your doctor or pharmacist tells you that we will not cover a prescription drug, you can contact us and ask for a coverage determination. The following are examples of when you may want to ask us for a coverage determination:

• If you are not getting a prescription drug that you believe may be covered by us.
• If we will not provide or pay for a Part D prescription drug that your doctor has prescribed for you because it is not on our list of covered drugs (called a "formulary"). You can request an exception to our formulary.
• If you disagree with the amount that we require you to pay for a Part D prescription drug that your doctor has prescribed for you. You can request an exception to the copayment/coinsurance we require you to pay for a drug.
• If you are being told that coverage for a Part D prescription drug that you have been getting will be reduced or stopped.
• If there is a limit on the quantity (or dose) of the drug and you disagree with the requirement or dosage limitation. You can request an exception by requesting that the requirement or limitation be removed.
• If there is a requirement that you use a generic equivalent of a drug. You can request an exception by requesting that this requirement be removed.
• You bought a drug at a pharmacy that is not in our network and you want to request reimbursement for the expense.

The process for requesting a coverage determination is discussed in greater detail below in the section titled "Detailed information about how to request a coverage determination and an appeal."

Who May Ask for a Coverage Determination?

You can ask us for a coverage determination yourself, or your prescribing doctor or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor, or anyone else to act for you. Some other persons may already be authorized under state law to act for you. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. This statement must be sent to us at:

WPS MedicareRx Plan
c/o Express Scripts
ATTN: Medicare Clinical Review Department
P.O. Box 66571
St. Louis, MO 63166-6571
1-800-935-6103 (Calls to this number are free)
(TTY 1-800-716-3231) Call hours are 24 hours a day, 7 days a week.
Fax: 1-877-251-5896

You can also call Customer Service to learn how to name your appointed representative.
Download the Appointment of Representative Form

You may use either of the forms shown below to request an exception if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower copayment or you wish to request a coverage determination. Select the link to one of the forms below and print them out so you can complete the form and send it to us at the addresses shown above.
Medicare Part D Coverage Determination Request Form
Your prescriber can help you request a coverage determination by submitting an electronic request to our prescription benefit manager by visiting the Express Scripts website.

Do You Have a Request for a Part D Prescription Drug That Needs to be Decided More Quickly Than the Standard Timeframe?

A decision about whether we will cover a Part D prescription drug can be a "standard" coverage determination that is made within the standard timeframe (typically within 72 hours) or it can be a "fast" coverage determination that is made more quickly (typically within 24 hours). A fast decision is sometimes called an "expedited coverage determination."

You can ask for a fast decision only if you or your doctor believes that waiting for a standard decision could seriously harm your health or your ability to function, and you have not already received the drug.

Asking for a Standard or a Fast Decision

To ask for a standard or a fast decision, you, your doctor, or your appointed representative should refer to our Customer Service numbers listed below for assistance. You can send a fax request to 1-877-251-5896, send a written request to:

WPS MedicareRx Plan
c/o Express Scripts
ATTN: Medicare Clinical Review Department
P.O. Box 66571
St. Louis, MO 63166-6571

Or you can all us at 1-800-935-6103 (TTY 1-800-716-3231.) Call hours are 24 hours a day, 7 days a week.

If your doctor asks for a fast decision for you, or supports you in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you a fast decision.

If you ask for a fast coverage determination without support from a doctor, we will decide if your health requires a fast decision. If we decide that your medical condition does not meet the requirements for a fast coverage determination, we will send you a letter informing you that if you get a doctor's support for a fast review, we will automatically give you a fast decision. The letter will also tell you how to file a "grievance" if you disagree with our decision to deny your request for a fast review. If we deny your request for a fast coverage determination, we will give you our decision within the 72-hour standard timeframe.

What Happens When You Request a Coverage Determination?

What happens, including how soon we must decide, depends on the type of decision.

• For a standard coverage determination about a Part D drug, which includes a request about payment for a Part D drug that you already received.
  Generally, we will give you our decision no later than 72 hours after we have received your request, but we will make it sooner if your health condition requires. However, if your request involves a request for an exception (including a formulary exception, tiering exception, or an exception from utilization management rules - such as dosage or quantity limits or step therapy requirements), we must make our decision no later than 72 hours after we have received your doctor's "supporting statement," which explains why the drug you are asking for is medically necessary. We must give you our decision within 14 calendar days after we receive your request about payment for a Part D drug that you already received. If you are requesting an exception, you should submit your prescribing doctor's supporting statement with the request, if possible.
  We will give you a decision in writing about the prescription drug you have requested. You will get this notification when we make our decision under the timeframe explained above. If we do not approve your request, we must explain why, and tell you of your right to appeal our decision. The section "Appeal Level 1" on the Appeals tab listed above explains how to file this appeal.
  If we have not given you an answer within 72 hours after receiving your request, your request will automatically go to Appeal Level 2, where an independent organization will review your case.
• For a fast coverage determination about a Part D drug that you have not received.
  If you get a fast review, we will give you our decision within 24 hours after you or your doctor asks for a fast review—sooner if your health requires. If your request involves a request for an exception, we must make our decision no later than 24 hours after we get your doctor's "supporting statement," which explains why the non-formulary or non-preferred drug you are asking for is medically necessary.
  We will give you a decision in writing about the prescription drug you have requested. You will get this notification when we make our decision, under the timeframe explained above. If we do not approve your request, we must explain why, and tell you of your right to appeal our decision. The section "Appeal Level 1" on the Appeals tab listed above explains how to file this appeal.
  If we decide you are eligible for a fast review, and we have not responded to you within 24 hours after receiving your request, your request will automatically go to Appeal Level 2 on the Appeals tab listed above, where an independent organization will review your case.
  If we do not grant your or your doctor's request for a fast review, we will give you our decision within the standard 72-hour timeframe discussed above. If we tell you about our decision not to provide a fast review by phone, we will send you a letter explaining our decision within three calendar days after we call you. The letter will also tell you how to file a "grievance" if you disagree with our decision to deny your request for a fast review, and will explain that we will automatically give you a fast decision if you get a doctor's support for a fast review.

What Happens if We Decide Completely in Your Favor?

If we make a coverage determination that is completely in your favor, what happens next depends on the situation.

• For a standard decision about a Part D drug, which includes a request about payment for a Part D drug that you already received.
  We must authorize or provide the benefit you have requested as quickly as your health requires, but no later than 72 hours after we received the request. If your request involves a request for an exception, we must authorize or provide the benefit no later than 72 hours after we get your doctor's "supporting statement." If you are requesting reimbursement for a drug that you already paid for and received, make payment to you no later than 30 calendar days after we get the request.
• For a fast decision about a Part D drug that you have not received.
  We must authorize or provide you with the benefit you have requested no later than 24 hours of receiving your request. If your request involves a request for an exception, we must authorize or provide the benefit no later than 24 hours after we get your doctor's "supporting statement.

What Happens if We Deny Your Request?

If we deny your request, we will send you a written decision explaining the reason why your request was denied. We may decide completely or only partly against your request. For example, if we deny your request for payment for a Part D drug that you have already received, we may say that we will pay nothing or only part of the amount you requested. If a coverage determination does not give you all that you requested, you have the right to appeal the decision.

We sent you information that explains your rights called an "Evidence of Coverage" (EOC). You have the right to ask us to provide or pay for a drug you think should have been covered while your plan was in effect. You have the right to request an appeal if you disagree with our decision about whether to pay for a drug.

You have the right to do all of these:

• Talk to your prescriber - your doctor or other health care provider who's legally allowed to write prescriptions. You can ask:
  • Whether the plan has special coverage rules
  • Whether there is generic, over the counter, or less expensive brand-name drugs that could work as well as the ones you're taking.
• Get a written explanation (called a coverage determination) from your Medicare drug plan. A coverage determination is the first decision made by your Medicare drug plan about your benefits, including these:
  • Whether a certain drug was covered
  • Whether you had met the requirements to get a requested drug
  • How much you would pay for a drug
  • Whether to make an exception to a plan rule when you request i
• Ask for an exception if:
  • You or your prescriber believes you needed a drug that wasn't on your plan's formulary.
  • You or your prescriber believes that a coverage rule (like prior authorization) should have been waived.
  • You think you should pay less for a higher tier (more expensive) drug because you or your prescriber believes you can't take any of the lower tier (less expensive) drugs for the same condition.
  • You disagree with your plan’s “at-risk determination” under a drug management program that limited your access to coverage for frequently abused drugs.

Note: Your doctor or other prescriber (for prescription drug appeals) can request this level of appeal for you, and you don’t need to appoint them as your representative. Your Medicare drug plan will send you a written decision. If you disagree with this decision, you have the right to appeal.

The appeals process has 5 levels. If you disagree with the decision made at any level of the process, you can generally go to the next level. At each level, you'll get instructions in the decision letter on how to move to the next level of appeal. Medicare explains the appeal levels on Medicare.gov and this will help you follow the process.

To file a standard appeal, you can send the appeal to us in writing at:

WPS MedicareRx Plan
c/o Express Scripts
ATTN: Medicare Clinical Appeals Department
P.O. Box 66588
St. Louis, MO 63166-6588
Fax: 1-877-852-4070

• In writing:
  

  WPS MedicareRx Plan
  c/o Express Scripts
  ATTN: Medicare Clinical Appeals Department
  P.O. Box 66588
  St. Louis, MO 63166-6588

• By fax, at 1-877-852-4070.
• By telephone-if it is a fast appeal-at 1-800-935-6103 (TTY 1-800-716-3231).
• By submitting an online request through Express Scripts, our prescription benefits manager.