Grievances

What is a grievance?

A grievance is a formal complaint that is not considered a coverage determination or appeal.

Reasons for filing a grievance include:

  • You suspect any type of fraud or abuse
  • You are unhappy with the condition of a pharmacy
  • You cannot understand the plan’s written information
  • You believe that your privacy was not respected
  • You are unhappy with how customer service handled
    a request or complaint
  • You were kept waiting too long at a pharmacy or by Customer Care
  • You are unhappy with the quality of the care you received
  • You feel that the plan’s marketing or sales activities are inappropriate
  • You disagree with any of our policies or benefit structure

How to file a grievance

  • Call our Customer Care Grievance Line at 1-866-884-9478, 24 hours a day, 7 days a week
  • TTY/TDD users, call 711
  • Fax to 1-866-217-3353
  • Write to:
    Blue MedicareRx (PDP) Grievance Department
    P.O. Box 30016
    Pittsburgh, PA 15222-0330

When to file

You need to file a grievance within 60 calendar days from the day the incident that prompted it occurred. We do not accept grievances filed after 60 days.

What information to provide

  • Your name
  • Your member ID number
  • The subject of the grievance
  • The date of the incident that caused the grievance
  • Your telephone number and address

Who can file a grievance

Only you or your appointed representative may file a grievance.

How to appoint a representative

To appoint someone to act as your legal representative, you and that person must submit our Appointment of Representative form, (PDF) or equivalent documentation, for each grievance. Equivalent documentation must state that your representative is authorized under state law to act on your behalf.

How soon will your grievance be decided

  • For a standard grievance, we have up to 30 calendar days from receipt of your grievance to make a decision.
  • All grievances are handled as “standard” except for grievances regarding our decision on an appeal or coverage determination.
  • For a fast grievance, we have up to 24 hours from receipt of your grievance to make a decision. If we decide to take extra days, we will tell you in writing.
  • Rarely, we may believe it is in your best interest for us to do more research on your grievance. In such a case, we may ask for up to an additional 14 days to decide.

How we notify you of our decision

We will notify you or your appointed representative by:

  • Phone if you called Customer Care to submit your grievance.
  • Letter if you submitted your grievance by mail or fax.

You or your doctor may Contact Us to check on the status of your grievance.

Where to find more information

For more information on appeals, see Chapter 7, Section 4, of our Evidence of Coverage document.

If you disagree with our decision

You can take your complaint to Medicare by downloading and submitting the Medicare Complaint Form. The Office of the Medicare Ombudsman (OMO) can help you with complaints, grievances, and information requests.


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