Drug Benefits

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Grievances and Appeals

SWH does its best to give you all the information you need to make the most of your benefits. We also listen to any concerns you may have. You have the right to make a complaint if you have concerns or problems related to your prescription drug coverage or the service you receive. "Appeals" and "grievances" are the two types of complaints you can make.

An "appeal" is a type of complaint you make when you want us to reconsider and change a decision we have made about your prescription drug benefits, and/or what we will pay for a prescription drug. For example, you can file an appeal if we do not cover or pay for a prescription drug you think we cover.

A "grievance" is a type of complaint you make if you have any other type of problem with the service you receive from us or one of our network pharmacies. For example, you would file a grievance if you have a problem with the waiting times when you fill a prescription, the way your network pharmacist or others behave, the availability of pharmacy staff by phone or otherwise, or the cleanliness or condition of a network pharmacy.

We have procedures to help ensure that appeals and grievances are answered in a timely manner. More information about these procedures is available elsewhere on this website and in your Evidence of Coverage you receive after you enroll.

You also have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug.

Coverage Determination

A coverage determination is the first decision we make about covering the drug you are requesting.

A coverage determination may be requested by:

A member
An appointed representative
A prescriber (the individual who prescribed the medication to the member)

Upon receipt of information needed to review a coverage request, the coverage determination is typically made within 72 hours. Expedited coverage determinations can be determined within 24 hours.

To initiate a coverage determination request, please call the Customer Service Center toll-free at the number listed on your identification card.

You will need the following information ready when you call:

Member name
Member date of birth
Member ID number
Name of the medication
Physician's phone number
Physician fax number (if available)

How to request an exception to your plan coverage determination

An exception is a type of coverage determination. Under certain circumstances, SWH may agree to provide you with an exception to one of these coverage determinations.

You may ask us to cover your drug even if it is not on our formulary. Excluded drugs cannot be covered by a Part D plan unless coverage is through an enhanced plan that covers those excluded drugs.
You may ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you may ask us to waive the limit and cover more.

Generally, we will only approve your request for an exception if the alternative drugs included on the Plan formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

Your doctor must submit a statement supporting your exception request. In order to help us make a decision more quickly, the supporting medical information from your doctor should be sent to us with the exception request.

Non-Formulary Prior Authorization Request Form

To request a prior authorization for a specific drug, please have your prescriber contact SWH Pharmacy department at 617-252-6366 or pharmacy@seniorwholehealth.com.

What to do if you have complaints?

SWH is dedicated to providing its members with comprehensive health care coverage. However, there may be times when you have concerns or problems related to your coverage or care. In these instances, you have the right to make formal complaints to SWH. If you make a complaint, we must be fair in how we handle it, and you cannot be disenrolled or penalized in any way.

There are two types of formal complaints you can make. They are appeals and grievances.

Member Appeals

Who can file an Appeal?

An appeal may be filed by any of the following:

You may file an appeal.
OR
Someone else may file the appeal for you on your behalf. You may appoint an individual to act as your representative to file the appeal for you by following the steps below:

Provide SWH with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider, a family member or friend, etc.)

For example: "I [your name] appoint [name of representative] to act as my representative in requesting an appeal from Senior Whole Health Plus (SWH) of NY HMO and/or CMS regarding the denial or discontinuation of medical services."
You must sign and date the statement.
Your representative must also sign and date this statement.
You must include this signed statement with your appeal.

What is an Appeal?

An appeal is a type of complaint you make when you want a reconsideration of a decision (coverage determination) that was made regarding a Part D drug. You cannot request an appeal if we have not issued a coverage determination. If we issue an unfavorable coverage determination, you may file an appeal called a "redetermination" if you want us to reconsider and change our decision.

When can an Appeal be filed?

You may file an appeal within sixty (60) calendar days of the date of the notice of the initial organization determination. For example, you may file an appeal for any of the following reasons:

We do not cover a Part D drug you think you are entitled to receive,
We do not pay you back for a Part D drug that you paid for,
We paid you less for a Part D drug than you think we should have paid you,
We ask you to pay a higher co-payment amount than you think you are required to pay for a Part D drug, or
We deny your exception request.

Note: The sixty- (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty- (60) day time frame.

Where can an Appeal be filed?

An appeal may be filed in writing directly to us or by contacting Member Services at the telephone number (or the TTY number for the hearing impaired) listed below. You may also contact Member Services and request the facsimile number for Appeals and Grievances.

Member Services: Our hours of operation are weekdays, Monday through Friday, from 8AM to 8PM, and also on Saturdays and Sundays from November 15th to March 1st. Someone is available, however, 24-hours a day, if assistance is needed. Interpreter services are available upon request.

1-866-211-1777 (toll-free)
1-866-404-9507 (TTY)

When will a Decision be made?

We must give you a response no later than 7 calendar days after we receive your appeal. If you need a faster decision (called an expedited appeal), contact Member Services at the telephone number (or the TTY number for the hearing impaired) listed in the paragraph above.

Why file an Appeal?

You may use the appeal procedure when you want a reconsideration of a decision (coverage determination) that was made regarding a Part D drug.

Fast Decisions/Expedited Appeals

You have the right to request and receive expedited decisions affecting your medical treatment in "Time-Sensitive" situations. A Time-Sensitive situation is a situation where waiting for a decision to be made within the time frame of the standard decision-making process could seriously jeopardize:

Your life or health, or
Your ability to regain maximum function.

If SWH or your Primary Care Physician, decides, based on medical criteria, that your situation is Time-Sensitive or if your covering PCP or specialist calls or writes in support of your request for an expedited review, SWH or your Primary Care Physician will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours after receiving the request.

Member Grievances

Who can file a Grievance?

A grievance may be filed by any of the following:

You may file a grievance.
OR
Someone else may file the grievance for you on your behalf. You may appoint an individual to act as your representative to file the grievance for you by following the steps below:

Provide SWH with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider, a family member or friend, etc.)

For example: "I [your name] appoint [name of representative] to act as my representative in requesting an appeal from Senior Whole Health Plus (SWH) of NY HMO and/or CMS regarding the denial or discontinuation of medical services."
You must sign and date the statement.
Your representative must also sign and date this statement.
You must include this signed statement with your grievance.

What is a Grievance?

A grievance is a type of complaint that expresses your dissatisfaction with the SWH or pharmacy's operations, activities or behavior.

For example, you would file a grievance:

when you feel waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room are too long
when you feel you are waiting too long for prescriptions to be filled;
if you are dissatisfied with the way your doctors, network pharmacists or others behave

When can a Grievance be filed?

You may file a grievance within sixty (60) calendar days of the date of the circumstance giving rise to the grievance. There is no filing limit for complaints concerning quality of care.

Note: The sixty- (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty- (60) day time frame.

Expedited Grievance

You have the right to request a fast review or expedited grievance if you disagree with SWH’s decision to invoke an extension on your request for a coverage determination or reconsideration, or SWH’s decision to process your expedited request as a standard request. In such cases, SWH will acknowledge your grievance within twenty-four (24) hours of receipt and notify you in writing of SWH’s conclusion within three (3) calendar days.

Where can a Grievance be filed?

A grievance may be filed in writing directly to us or by contacting Member Services at the telephone number (or the TTY number for the hearing impaired) listed below. You may also contact Member Services and request the facsimile number for Appeals and Grievances.

1-866-211-1777 (toll-free)
1-866-404-9507 (TTY)

When will you get a response?

We must give you a response no later than 30 calendar days after we receive your grievance. If you would like to inquire about the status of a grievance please call the Customer Service toll-free number listed on your identification card.

Why file a Grievance?

You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with SWH or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information.

How to obtain an aggregate number of grievances, appeals, and exceptions filed with the plan.

To request information about the aggregate number of grievances, appeals and exceptions, please contact SWH Customer Service. Customer Service is available, 8AM to 8PM, 7-days-a-week.

Evidence of Coverage

SWH’s Evidence of Coverage also discusses the grievance, coverage determination (including exceptions) and appeals process in Sections 8 and 9.

Download the SWH 2010 Evidence of Coverage (PDF)

To download the SWH Evidence of Coverage, you must have Adobe Acrobat Reader installed. If you do not have Adobe Acrobat Reader installed on your computer, click here to download and install a free version of Adobe Acrobat Reader or click on the Adobe Acrobat Reader icon below.

To search an Adobe PDF file using Adobe Acrobat Reader, click on the "Search" icon (the button with the binoculars) on the Acrobat file toolbar or choose "Edit > Search" from the Acrobat menu. In the "Search PDF" window that opens, type in the word or phrase you are looking for and click on "Search".

The cursor will jump to the first place in the document that word or phrase appears and a search results box will also appear listing all the occurrences of that word or phrase. You can jump to any particular instance of the word or phrase by clicking on that item in the results box. You can also use the "Edit > Search Results > Next Result" or "Edit > Search Results > Previous Result" in the Acrobat menu to navigate forwards or backwards to the next item.

If you have questions regarding SWH’s 2010 Evidence of Coverage please contact us.

1-866-211-1777 (toll-free)
1-866-404-9507 (TTY)

Our hours of operation are weekdays, Monday through Friday, from 8AM to 8PM, and also on Saturdays and Sundays from November 15th to March 1st. Someone is available, however, 24-hours a day, if assistance is needed. Interpreter services are available upon request.

Determination Request Forms

For use by Members:
Medicare Prescription Drug Determination Request Form (PDF)

For use by Providers:
Medicare Part D Coverage Determination Request Form (PDF)

To download the forms, you must have Adobe Acrobat Reader installed. If you do not have Adobe Acrobat Reader installed on your computer, click here to download and install a free version of Adobe Acrobat Reader or click on the Adobe Acrobat Reader icon below.

Last modified: 06/21/2010