PERS ODS Advantage Rx (PDP) appeal and grievance procedure

Our goal is to provide you with coverage and services that always exceed your expectations. However, if you have concerns or problems with any part of your benefits, care or service, as a PERS ODS Advantage Rx member, you have the right to file a complaint.

There are two types of complaints: appeals and grievances.

Appeal

You can make an appeal if you disagree with a coverage decision we have made, your benefits and/or coverage of your prescription drugs, including problems related to payment. An appeal is a formal way of asking us to review and change a coverage decision we have made. Our Annual Notice of Changes – Evidence of Coverage for the PERS ODS Advantage Rx plan, Chapter 7 includes an explanation of appeals, including the process involved in making an appeal.

Grievance

A grievance is a type of complaint you make about Moda Health or one of our network providers, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes. Our Annual Notice of Changes - Evidence of Coverage, Chapter 7 includes more information about a complaint and how to make one.

• What to do if you have a problem or complaint - If you have a problem or complaint, please refer to your  Annual Notice of Changes - Evidence of Coverage for the PERS ODS Advantage Rx plan, Chapter 7. This document covers how to ask for a coverage decision or make an appeal.
• How to make a complaint about quality of care, waiting times, customer service, or other concerns - If you would like more information on how to make a complaint, your Annual Notice of Changes - Evidence of Coverage for the PERS ODS Advantage Rx plan document provides more information in Chapter 7.

If you have questions or need help with your appeal, coverage determination, exception request, redetermination or grievance, please call customer service.

You can mail coverage determinations and exception requests to:

Moda Health Plan, Inc.
Attn: ODS Advantage Pharmacy Customer Service
P.O. Box 40327
Portland, OR 97240-0327
You may also fax to: 800-207-8235

You can mail appeals, complaints and redeterminations to:

Moda Health Plan, Inc.
Attn: ODS Advantage Appeals
P.O. Box 40384
Portland, OR 97240-0384
You may also fax to: 503-412-4003

For a report on the number of PERS ODS Advantage Rx grievances, appeals and exceptions, call member services.