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Exceptions and Appeals

We encourage you to let us know right away if you have questions, concerns, or problems related to the HOP Basic Medicare Rx Option or the HOP Enhanced Medicare Rx Option. Please call our Customer Service numbers as follows:

  • For questions regarding the HOP Basic or Enhanced Rx Option including the formulary, prior authorizations, mail service orders, Explanation of Benefits (EOB) or the cost of individual drugs, please call OptumRx at 1-888-239-1301.
  • For questions regarding eligibility, monthly premium payments, identification cards or changes in address, please call the HOP Administration Unit at 1-800-773-7725.

Following is a summary of Appeals and Grievances regarding the HOP Basic and Enhanced Medicare Rx Options. For more detail, see the 2015 Annual Notice of Change and Evidence of Coverage (PDF 1.37MB).

Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a participant of a Medicare Rx plan. Making a complaint will not affect your participation in this Plan in any way. A complaint will be handled as either a coverage determination, an appeal, or a grievance, depending on the subject of the complaint. The following sections describe each type of complaint.

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 determining both whether to provide or pay for a Part D drug and your share of the cost. Coverage determinations include requests for an exception. 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 co-payment. If you request an exception, your doctor must provide a statement to support your request, and your request must meet this Plan’s criteria for an exception.

You must contact OptumRx Customer Service 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. Use the link below to download the necessary form or to contact OptumRx:

Who may ask for a coverage determination?

You can ask us for a coverage determination yourself, or name someone else as your appointed representative . You can name a relative, friend, advocate, doctor, or anyone else to act for you. Another person may already be authorized under state law to act for you. To name an appointed representative, 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 OptumRx, Inc., 3515 Harbor Blvd, Mail Stop CA106-0264, Costa Mesa, CA 92626. You also have the right to have an attorney ask for a coverage determination on your behalf. You can contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify.

CMS’ Appointment of Representative Form (Form CMS-1696) (PDF 67K)

What is an appeal?

An appeal deals with the review of an unfavorable coverage determination. You file an appeal if you want us to reconsider a decision about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.

What is a grievance?

A grievance is any complaint other than one that involves a coverage determination. A grievance is different from a request for a coverage determination because it 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 discussed above.)

You 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 would 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

If you have a grievance, we encourage you to first call OptumRx Customer Service at 1-888-239-1301. We will try to resolve your concern 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 will follow a formal review procedure called “Processing of Expedited and Standard Grievances for Medicare Part D.” Within this process, your grievance will be handled by the Part D Appeal & Grievance Department in accordance with CMS guidelines. You may submit your grievance to the Part D Appeal & Grievance Department by mail, phone, fax or email to:

  • Mail to Part D Appeal & Grievance Department, 5757 Plaza Drive, Mail Stop CA 124-0197, Cypress, CA 90630
  • Phone by calling 1-888-239-1301
  • Fax to 1-866-308-6294

You will be notified of the grievance ruling within 30 calendar days of the date the grievance was filed. Exceptions to the 30-day ruling timeframe may be made in accordance with CMS guidelines to accommodate extensions and expedited issues. If your grievance involves a refusal to grant an expedited coverage determination or expedited appeal and you have not yet purchased or received the drug in dispute, the grievance ruling will be communicated to you within 24 hours of receipt. 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 timeframe 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.