Pharmacy Resources

If the Plan says no to your Coverage Determination or Exceptions request, you have the right to request an appeal (redetermination) or a grievance. 

There are two types of formal process for handling problems and concerns about prescription drugs, the Appeals Process and the Grievance Process: 

You can request an Appeal (Redetermination) when a prescription drug was denied by the plan that the member believes he or she is entitled to receive. You have the right to ask us for a redetermination (appeal) of our coverage decision, this is considered a Level 1 Appeal. You or your representative must ask for an appeal in writing. If requested by a representative, there are additional steps necessary before the request can be processed (please see the AOR process below). You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. The plan will provide a response to your request no later than 7 calendar days from receipt date of your appeal request. 

Expedited (Fast) Appeal 

If you or your prescriber believe that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision.  If your prescriber indicates that waiting 7 days could seriously harm your health, we will automatically give you a decision within 72 hours.  If you do not obtain your prescriber’s support for an expedited appeal, we will decide if your case requires a fast decision.  You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received. 

Request For Redetermination of Medicare Prescription Drug Denial 

• Request for Redetermination of Medicare Prescription Drug Denial – English [PDF] 

• Request for Redetermination of Medicare Prescription Drug Denial – Spanish [PDF] 

You can ask for a Redetermination by:   

• Phone: Call Member Services at 1-800-838-8271, TTY: 711  
• Fax: Submitting a written request or a completed Imperial Health Plan Redetermination Form by fax to 1-626-380-9049  

• Please complete your form and mail to:   Imperial Health Plan of California, Inc 

                                                                                              Attn: Appeals & Grievances   

                                                                                              PO Box 60874   

                                                                                              Pasadena, CA 91116   

Independent Review Organizations; also known as Independent Review Entity (IRE) 

The IRE, MAXIMUS Federal Services, is an independent organization that is hired by Medicare (not the plan). If our plan denies your Level 1 Appeal, you then can choose whether to accept this decision or continue making another appeal. If you decide to go on to a Level 2 appeal, the IRE will review the plan’s decision when we said no to your first appeal. The IRE decides whether the decision we made should be changed. 

Standard Grievance 

If you are asking for a standard grievance regarding a complaint or dispute about a non-covered prescription drug or an excluded drug you can request this in any of the ways listed below. The plan will provide a response to you no later than 30 calendar days from receipt date of your grievance. 

Expedited (Fast) Grievance 

A fast complaint can be requested for the following reasons: 

• If we denied your request for a ‘fast coverage decision’ or a ‘fast appeal’, we will automatically give you the option to request a ‘fast complaint’ 
• If we have requested to take an additional 14 days to resolve your appeal or complaint, and you believe we should not take extra days, you can file a “fast complaint”. 

If you have a “fast complaint” which meets the above criteria we will give you an answer within 24 hours. 

Appointment of Representative Form 

This form confirms your request for a person, other than yourself, to act as your representative in connection with an appeal of grievance (complaint) request and must be completed and received before the plan can process your request. 

You can download the Appointment of Representative Form by clicking on your preferred language below. 

• Appointment of Representative Form – English [PDF, 228KB] 

• Appointment of Representative Form – Spanish [PDF, 378KB] 
• Appointment of Representative Form – Chinese [PDF, 350KB] 

Please complete your form and mail to:  Imperial Health Plan of California, Inc 

                                                                             Attn: Appeals & Grievances   

                                                                             PO Box 60874   

                                                                             Pasadena, CA 91116   

You may also fax your form to:  1-626-380-9049 

If you or your providers have any questions regarding this process, while completing this form, or would like to get the status of an open case, please call our Member Services at: 1-800-838-8271. 

You can also refer to Chapter 9 What to do if you have a problem of complaint (coverage decisions, appeals, complaints) in your Evidence of Coverage for more information about appeals and grievances. 

Or visit the following Medicare websites for additional information on coverage determinations, exceptions and redeterminations. 

If you or your providers have any questions regarding this process, while completing this form, or would like to get the status of an open case, please call our Member Services at: 1-800-838-8271.