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Medicare Appeals & Grievances

Provider Directory Precertification Request Form

Formulary Shingles Vaccine Info. Rx Mail Order Form Out of Area Coverage Drug Management Programs Medication Therapy Management Programs Drug Exclusions Rx Determination Request Form Part D Coverage Determination Request Form Rx Prior Authorization

Complaints about Rx Coverage? How to File a Grievance How to File an Appeal Appoint a Representative Appeal & Grievance Form

Who Can Join? Summary of Benefits Evidence of Coverage Quality Program Ending Your Membership Disclaimers

Extra Help for Premiums

Complaints about Rx Coverage

Please click on the link above for more information.

How to File a Grievance

The formal name for “making a complaint” is “filing a grievance.” Please click on the link above for more information.

An appeal is something you do if you disagree with a decision to deny a request for health care services or prescription drugs or payment for services or drugs you already received. Please click on the link above for more information.

Appeal & Grievance Form

Appoint a Representative

Please complete and return the above form to appoint an individual to act on your behalf.

Updated 1/2010

H3044_H1558_WHPWeb (10/2009)