Grievances

What is a grievance?
A “grievance” is a type of complaint you have with SilverScript or one of our network pharmacies that is not considered a coverage determination or appeal issue. 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 getting the information you need, or the cleanliness or condition of a network pharmacy.

Reporting Fraud and Abuse
We encourage you to report to us any instances of potential fraud or abuse related to your prescription drug plan. Potential fraud and abuse occurs when some person or entity, such as a physician, pharmacy, pharmacist, SilverScript or another Part D plan or an enrollee intentionally deceives others or misrepresents information in order to gain some improper benefit related to the plan. Examples of potential fraud and abuse include forging or altering prescriptions, deliberately billing incorrectly for drugs or premiums, doctor shopping (usually to get multiple prescriptions for the same drug), drug shorting (dispensing fewer drugs than stated), and deliberately failing to disclose other drug coverage.

What types of items might lead to filing a grievance?

  • Unresolved issues with the Customer Care
  • Problems with your pharmacy service
  • Disagreement with any of our policies or benefit design
  • Suspicion of fraud or abuse
  • Marketing or sales activities that you feel are inappropriate

How do I file a grievance?
If you have a grievance, we encourage you to call our Customer Care Grievance Line at (866) 884-9478. You may submit a grievance by fax at (866) 217-3353 or in writing to: SilverScript Grievance Team, P.O. Box 53991, Phoenix, AZ 85072-3991

How soon do I need to file a grievance?
You will need to file your grievance within 60 calendar days from the date the incident that prompted it occurred. We will not accept grievances filed more than 60 days after the incident occurred.

What information do I need to provide when I file a grievance?
We will need to know your name, your ID number and the nature of the grievance including the date the incident resulting in the grievance occurred. Also, be sure to provide your telephone number and address so we can notify you of our decision.

Can someone else file a grievance for me?
Only you, or your appointed representative, may file a grievance. If you use a representative, a copy of the signed SilverScript Appointment of Representative form must be submitted for each grievance and is valid for one year. We believe it is important to protect your health information and only provide it to those individuals you have appropriately authorized to act on your behalf.

Appointing a representative
If you want to name a relative, friend, advocate, doctor, or anyone else to act for you as your appointed representative, you and that person will need to complete and sign the SilverScript Appointment of Representative form. By completing this form you give that person legal permission to act as your appointed representative for your grievance. Please submit this form to our Grievance Department at the address provided in the above section on How to file a Grievance. If you prefer you may fax the form to the fax number also provided in that section.

How soon will my grievance be decided?
How quickly we decide on your grievance depends on the type of grievance:

  • For a standard grievance, we have up to 30 calendar days from receipt of your grievance to make a decision.
  • For a fast grievance, we have up to 24 hours from receipt of your grievance to make a decision.
  • All grievances are handled as “Standard” except in certain instances of a grievance filed with respect to our decision on an appeal or coverage determination. Rarely, but in some cases, we may notify you that we need additional time to research the grievance and we believe it is in your best interest for us to continue researching the grievance. We may ask for up to an additional 14 days.

How will you notify me of your decision?
We will notify you or your appointed representative by phone if you submit a grievance verbally while on the phone with a Customer Care Representative.
We will notify you or your appointed representative by letter when you submit a grievance in writing (letter or fax) or upon your request.

What if I disagree with your decision on my grievance?
Per Medicare regulations, all grievance decisions are final and not eligible for review or appeal.

Coverage Determination Process
Appeals
Grievances and Appeal Policies