Use this 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 this form.
For Provider Disputes of claim billing denials or contract payment amounts, please use the Provider Dispute Form
For other complaints, please use the Customer Complaint Form
If you need help filling out this form, call us at 877-358-8797. (Si necesita ayuda para llenar o completar este formulario, llamenos al 877-358-8797)
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