Appeals, Complaints and Coverage Decisions

Medicare uses a lot of formal terms when it comes to appeals, complaints and coverage decisions. If you have a complaint, you file a grievance. If your doctor wants you to have a medical service or prescription drug and you're not sure if your plan will cover it, you can ask us to make a coverage decision. And if you disagree with our decision, you appeal.

Fortunately, contacting us is simpler than the terminology. If you have a Medicare Advantage or a Prescription BlueSM PDP plan, for all these things you can start by calling the customer service number on the back of your Blues ID card. Learn more about appeals, complaints and coverage decisions in our frequently asked questions below.

Frequently asked questions

Forms and documents

Requesting a report

We want you to be informed about our plans. That includes sharing how many grievances and appeals have been filed by members. We can also tell you about the number of exceptions—when we've approved a prescription for a drug not on your plan's drug list or waived rules around it.

To get a report, call the Customer Service number on the back of your Blues ID card. If you don't have that number handy or would like to mail your request, you'll find phone numbers and addresses in contact us.

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