APPEALS, GRIEVANCES AND EXCEPTIONS FOR PART D

A summary of the plan's grievance, coverage determination (including exceptions), and appeals process is listed here: Evidence of Coverage (2008) - Section 10, Page 81.  Please call DAKOTACARE Customer Service, toll-free, at 1-866-437-3288 for assistance or clarification. Coverage Determinations Express Scripts, Inc. makes a coverage determination about your Part D prescription drugs, or about paying for a Part D prescription drug you have already received.  The coverage determination is the starting point for dealing with requests you may have about covering or paying for a Part D prescription drug.  If your doctor or pharmacist tells you that a certain Part D prescription drug is not covered, you should contact Express Scripts, Inc. and ask for a coverage determination. To contact Express Scripts, Inc. regarding coverage determinations, you or your doctor can call 1-800-417-8164, 24 hours a day, 7 days a week.  Your physician can also submit a form to request a coverage determination.  To download a copy of this request form, please click here:

Request for Medicare Presecription Drug Coverage doc (514k)

You may designate a representative to request coverage determinations or file appeals on your behalf.  To do so, please click this link to the authorized CMS form:  Appointment of Representative (CMS-1696). Appeals An appeal is any of the procedures that deal with 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. You may initiate or receive help with an appeal by calling DAKOTACARE Customer Service, toll-free, at 1-866-437-3288.  An appeal may also be filed in writing by mailing it to: 2600 W. 49th Street P.O. Box 7406 Sioux Falls, SD 57117-7406 or by faxing it to 605-334-8717. Grievances A grievance is different from a request for a coverage determination or appeal because it usually will not involve coverage or payment for Part D prescription drug benefits.  Types of problems that might lead you to file a grievance might include:  you feel you are being encouraged to leave (disenroll from) HeartLine Plus, you are dissatisfied with the Customer Service you receive from the plan, you experience problems related to a plan pharmacy, you feel that the plan has failed to meet its obligations to comply with CMS standards, etc. To file a grievance, please call DAKOTACARE Customer Service, toll-free, at 1-866-437-3288; or write to: 2600 W. 49th Street P.O. Box 7406 Sioux Falls, SD 57117-7406 This page was last updated on 4/14/2008.