Please use the Customer Appeal Form to appeal an adverse benefit determination (denied or limited authorization request) or a claim benefit denial where the member could be liable for payment.
For Retail Pharmacy appeals (a medication dispensed to a member from a retail or specialty pharmacy), please use the Retail Pharmacy Appeal Form.
For Medical Pharmacy appeals (a medication administered to a member in a facility setting, provider or infusion center, or in the home dispensed from a home infusion pharmacy), please use the Appeal Form.
For Provider Disputes of claim billing denials or contract payment amounts, please use the Provider Dispute Form.
For any other concerns, complaints or grievances, please use this form.
If you need help filling out this form, call us at 855-447-2900 (TTY Users: 800-346-4128, or dial 711).