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What to do if you have complaints about your Part D prescription drug benefits

We encourage you to let us know right away if you have questions, concerns, or problems related to your prescription drug coverage. Please call Member Services at 800-446-8331.

Please note that section 12 addresses complaints about your Part D prescription drug benefits. If you have complaints about your MA benefits, you must follow the rules outlined in sections 10 and 11.

This section gives the rules for making complaints in different types of situations. Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan member. The Medicare program has helped set the rules about what you need to do to make a complaint and what we are required to do when we receive a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from MediSunONE or penalized in any way if you make a complaint.

A complaint will be handled as a grievance, coverage determination, or an appeal, depending on the subject of the complaint. The following section briefly discusses grievances, coverage determinations, and appeals.

A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with MediSun Health Plan, MediSunONE 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.

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 making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exceptions requests. 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 copayment. If you request an exception, your physician must provide a statement to support your request.
You must contact us 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.

An appeal is any of the procedures that deal with the review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.

This part of Section 12 explains how to file a grievance. 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 below).

Problems with how long you have to spend waiting on the phone or in the pharmacy.

If you disagree with our decision not to expedite your request for an expedited coverage determination or redetermination.

You believe our notices and other written materials are difficult to understand.

Failure to forward your case to the independent review entity if we do not give you a decision within the required timeframe.

In certain cases, you have the right to ask for a “fast grievance,” meaning your grievance will be decided within 24 hours. We discuss these fast-track grievances in more detail below.

If you have a concern, we encourage you to first call Member Services at the number on the cover of this booklet. We will try to resolve any concern that you might have over the phone. If you request a written response to your phone concern, we will respond in writing to you. If we cannot resolve your concern to your satisfaction over the phone, we have a formal procedure to review your complaint. We call this “filing a grievance”. To file a grievance, you, as a current member of MediSunONE, or your authorized representative, must write a complete description of your grievance including as many details as possible (names, dates, time of the occurrence, etc.) and send it to MediSun Health Plan Attention: Grievance & Appeals Coordinator P.O. Box 1489, Sun City AZ 85372. You may also deliver your written grievance to our office at MediSun Health Plan Attn: Grievance & Appeals Coordinator 13632 N. 99th Ave. Suite B, Sun City, AZ 85351.

The Coordinator accepts all grievances from current plan members (or their authorized representative) for processing. An investigation will be conducted into your grievance. 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.
If you are dissatisfied with the resolution to your grievance, you can request a grievance hearing. Your request for a grievance hearing should be delivered to the Grievance & Appeals Coordinator using the information provided above within 30 days of the date of the grievance resolution letter. The request for a grievance hearing should state why you are dissatisfied with the initial resolution and include any additional information or documentation you may have related to the grievance. Should a hearing be warranted based on the additional information/documentation provided, you will be asked to appear before a panel of Committee members at a time designated by MediSun Health Plan. Upon completion of the grievance hearing, you will be notified of the final resolution in writing within ten (10) days.

You have the right to request an expedited grievance in special circumstances, such as:

If we deny you request to give you a fast decision (expedited initial determination) about whether MediSun Health Plan will pay for your prescription drug.
If we deny your request to give you a fast appeal (expedited reconsideration) about whether MediSun Health Plan will reconsider our original decision not to pay for your prescription drug.
If you disagree with our decision to take an extension of time (usually 14 days) to make a decision (initial determination) or process your appeal (reconsideration) about whether to pay for your prescription drug.

If one of these circumstances applies to your situation, you can file an expedited grievance by sending a detailed written description of your expedited grievance to MediSun Health Plan Attn: Grievance & Appeals Coordinator at P.O. Box 1489, Sun City, AZ 85372. You can also deliver your expedited grievance to our office at MediSun Health Plan Attn: Grievance & Appeals Coordinator 13632 N. 99th Ave. Suite B, Sun City, AZ 85351 or you can fax your expedited grievance to 623-974-7495 (Attn: Grievance & Appeals Coordinator). The Coordinator will acknowledge receipt of your expedited grievance by telephone within 24 hours of receipt and conduct an investigation. You will be sent a resolution letter within 72 hours.