Getting the Most Out of Your Plan

Grievance and Appeals

• Part D (Prescription Drug) Grievances and Appeals
• How to file a pharmacy appeal (Part D Redetermination)
• Part C (Medical Services) Grievances and Appeals
• Appointed Representatives

Written requests for Reconsideration, Redetermination, and Grievances can be sent to this address by mail:

Highmark Wholecare
Attn: Member Appeals Department
P.O. Box 22278
Pittsburgh, PA 15222

To fax your request: 412-255-4503

To make your request by telephone:
Call Member Services from 8:00 AM - 8:00 PM Eastern Time 7 Days a week from October 1 through March 31. April 1 through September 30, our hours are 8 am to 8 pm, Monday through Friday.

• 1-800-685-5209 in Pennsylvania (TTY users: 711)

What happens to you if we leave the Medicare program or Highmark Wholecare Medicare Assured leaves the area where you live?

We have a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs Medicare. This contract renews each year. At the end of each year, the contract is reviewed, and either we or CMS can decide to end it. You will get 90 days advance notice in this situation. It is also possible for our contract to end at some other time during the year, too. In these situations we will try to tell you 90 days in advance, but your advance notice may be as little as 30 or fewer days if CMS must end our contract in the middle of the year.

If we leave the Medicare program or changes its service area so that it no longer includes the area where you live, we will tell you in writing. If this happens, your membership in Highmark Wholecare Medicare Assured will end, and you will have to change to another way of getting your Medicare benefits. Your choices for how to get your Medicare will always include Original Medicare and joining a Prescription Drug Plan to complement your Original Medicare coverage. Your choices may also include joining another Medicare Advantage Plan, or a Private Fee-for-Service plan, if these plans are available in your area and are accepting new members.