Grievance Process

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Appeals and grievances: What to do if you have complaints
We encourage Prescription Pathway members to contact us with questions, concerns, or problems related to prescription benefits. Please call us at 888-875-0774 to discuss your concerns. Complaints and inquiries are grouped by type. Federal law guarantees Prescription Pathway members’ rights to make complaints regarding concerns or problems with any part of the plan. The Medicare program has helped set the rules about what’s needed to make a complaint, and what Prescription Pathway is required to do when we receive a complaint. If a complaint is filed, we must be fair in how we handle it. A Prescription Pathway member may not be disenrolled from Prescription Pathway or penalized in any way for making a complaint.

What are appeals and grievances?
Prescription Pathway members have the right to make a complaint regarding concerns or problems related to coverage or care. “Appeals” and “grievances” are the two different types of complaints that can be filed.

An “appeal” is the type of complaint a member can make when the member wants Prescription Pathway to reconsider and change a decision we have made about what prescription drug benefits are covered or what we will pay for a prescription drug. For example, if we refuse to cover or pay for a prescription drug a member thinks we should cover, an appeal can be filed. If Prescription Pathway refuses to provide a prescription drug the member thinks should be covered, the member can file an appeal. If Prescription Pathway reduces or cuts back on the prescription drugs a member has been receiving, the member can file an appeal. If the member thinks we are stopping prescription drug coverage too soon, the member can file an appeal.

A “grievance” is the type of complaint a member can make if the member has any other type of problem with Prescription Pathway or one of our network pharmacies. For example, a member should file a grievance if the member has problems with things such as waiting times when filling a prescription, the way the network pharmacist or others behave, being able to reach someone by phone or getting the needed information, or the cleanliness or condition of a network pharmacy.

A grievance is different from an appeal because usually it 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 appeals process discussed above).

What types of problems might lead to you filing a grievance?

•	If a member feels that he or she is being encouraged to leave (disenroll from) Prescription Pathway.
•	Problems with customer service.
•	Problems with how long a member has to spend waiting on the phone or in the pharmacy.
•	Disrespectful or rude behavior by pharmacists or other staff.
•	Cleanliness or condition of pharmacy.
•	If a member disagrees with our decision not to expedite a request for an expedited coverage determination or re-determination.
•	A member believes our notices and other written materials are difficult to understand.
•	Prescription Pathway failure to make a decision within the required time frame.
•	Prescription Pathway failure to forward a member’s case to the independent review entity if we do not make a decision within the required time frame.

In certain cases, a member has the right to ask for a “fast grievance,” meaning the grievance will be decided within 24 hours.

Filing a grievance with Prescription Pathway
If a member has a grievance, we encourage members to first call Prescription Pathway Customer Service at 888-875-0774. We will try to resolve any complaints over the phone. If a member requests a written response to a phone complaint, we will respond in writing. If we cannot resolve the complaint over the phone, we have a formal procedure to review complaints. If a member is dissatisfied with the service provided, such as sales, enrollment or services processes the member has the right to file a grievance with the plan. Please send grievances to Prescription Pathway-Grievance Department, 1001 Heathrow Park Lane, Suite 5001, Lake Mary, FL 32746, or you may fax them to 513-341-2800.

The plan will review the grievance and take corrective action as necessary. A grievance does not involve an appeal or coverage determination. 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. Prescription Pathway members are encouraged to consult the Evidence of Coverage for complete details for filing grievances.

You are entitled to obtain an aggregate number of grievances, appeals, and exceptions filed with Prescription Pathway. You may do so by filing a written request with Prescription Pathway to Prescription Pathway Grievance Department, 1001 Heathrow Park Lane, Suite 5001, Lake Mary, FL 32746.

Last updated: 10/01/2007