For Members

Coverage Decisions, Appeals & Grievances

Coverage Decisions

A coverage decision is a decision we make about your medical care or prescription drug benefits and coverage or about the amount we will pay for your medical care services or prescription drugs.


An appeal is a formal way of asking us to review and change a coverage decision we have made.


A grievance is a complaint you make about us or one of our network providers or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage decisions or appeals.

Detailed information about Coverage Decisions, Appeals and Grievances can be found in the 2024 Evidence of Coverage.