Exceptions, Grievances and Complaints

These instructions don't apply to members of Priority Health Medigap (Medicare supplement) plans.

The Medicare program has rules about what members of Priority Health Medicare plans need to do to ask for exceptions or make grievance about their coverage or their service, and how we must handle their requests and grievance.

• We must be fair in how we handle it.
• You can't be disenrolled from a Priority Health Medicare plan or penalized in any way.

Step one:

If you have a concern, call Customer Service. We might be able to answer your question or resolve your concern over the phone.

Step two:

Ask for an exception for coverage of prescription drugs that are not on the formulary or are on the formulary with limits or restrictions. (Coverage determination)	Request a coverage decision for medical services (Organization determination)	Or, file a grievance about service
Ask for an exception for a drug that you believe should be covered by your plan. Learn how to appeal if our decision is not in your favor. Exception instructions	Formally request a coverage decision for medical services that you believe should be covered by your plan. Learn how to appeal if our decision is not in your favor. Coverage decision instructions	Make a grievance about the service(s) you receive from us or from our network of doctors, hospitals, pharmacies and other health care providers. Service complaint instructions

To file a complaint directly with Medicare, use their complaint form on medicare.gov.

Numbers of grievances and appeals

To find out the combined number of grievances, appeals and exceptions filed with Priority Health Medicare plans, call Customer Service.