Part D Appeals

An appeal is the process to review a decision we made that you may not like. The negative decision is called a Coverage Determination. You would file an appeal if you want us to review it again and change our mind about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.

When our answer is no to part or all of what you asked for, we will send you a letter that explains why we said no. The letter will also explain how you can appeal our decision. You must make your appeal within 60 days from the date on the letter we sent to you. If you have a good reason for sending your appeal after the 60 days, we might give you more time.

We have seven calendar days to answer your standard appeal request.  For urgent or fast (expedited) appeals, we will respond within 72 hours.

Filing an appeal:

You, your doctor, or your appointed representative can call, mail, or fax an appeal one of the following ways:

For denials of medical appeals for Medicare covered services (including services that are covered by both Medicare and Medi-Cal): 

If we deny any part of your medical appeal, your case will be sent to an independent review organization. This independent review organization contracts with the Federal government and is not part of our Plan.

If you have questions about the Part D Prescription Drug appeals procedures, you may refer to the sections of the Member Handbook for your plan as outlined below. You may also call us at 1-855-464-3571 (TTY: 711) Los Angeles; 1-855-464-3572 (TTY: 711) San Diego County. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day.

An appeal is the process to review a decision we made that you may not like. The negative decision is called a Coverage Determination. You would file an appeal if you want us to review it again and change our mind about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.

When our answer is no to part or all of what you asked for, we will send you a letter that explains why we said no. The letter will also explain how you can appeal our decision. You must make your appeal within 60 days from the date on the letter we sent to you. If you have a good reason for sending your appeal after the 60 days, we might give you more time.

We have seven calendar days to answer your standard appeal request.  For urgent or fast (expedited) appeals, we will respond within 72 hours.

Filing an appeal:

You, your doctor, or your appointed representative can call, mail, or fax an appeal one of the following ways:

For denials of medical appeals for Medicare covered services (including services that are covered by both Medicare and Medi-Cal): 

If we deny any part of your medical appeal, your case will be sent to an independent review organization. This independent review organization contracts with the Federal government and is not part of our Plan.

If you have questions about the Part D Prescription Drug appeals procedures, you may refer to the sections of the Member Handbook for your plan as outlined below. You may also call us at 1-855-464-3571 (TTY: 711) Los Angeles; 1-855-464-3572 (TTY: 711) San Diego County. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day.