Appealing a Denied Claim

In the event you receive an adverse benefit determination following a request for coverage of a prescription benefit claim, you have the right to appeal the adverse benefit determination in writing within 180 days of receipt of notice of the initial coverage decision. To initiate an appeal for coverage, you or your authorized representative (such as your physician), must provide in writing, your name, member ID, phone number, the prescription drug for which benefit coverage has been denied, and any additional information that may be relevant to your appeal. This information should be made in writing to:

OptumRx Member Services
P.O. Box 3410
Lisle, IL 60532-8410
Phone:  1-888-863-8578

A decision regarding your appeal will be sent to you within 15 days of receipt of your written request. The notice will include the specific reasons for the decision and the plan provisions on which the decision is based. You have the right to receive, upon request and at no charge, the information used to review your appeal. If you are not satisfied with the coverage decision made on appeal, you may request in writing, within 180 days of the receipt of notice of the decision, a second level appeal. To initiate a second level appeal, you or your authorized representative (such as your physician), must provide in writing your name, member ID, phone number, the prescription drug for which benefit coverage has been denied, and any additional information that may be relevant to your appeal. This information should be mailed to:

OptumRx Member Services
P.O. Box 3410
Lisle, IL 60532-8410
Phone:  1-888-863-8578

A decision regarding your request will be sent to you in writing within 15 days of receipt of your written request for appeal. You have the right to receive, upon request and at no charge, the information used to review your second level appeal. The decision made on your second level appeal is final and binding. If you are not satisfied with the decision of the second level appeal, you also have the right to bring a civil action under section 502(a) of the Employee Retirement Income Security Act of 1974 (ERISA) if your second level appeal is denied.  In the case of a claim for coverage involving urgent care, you will be notified of the benefit determination within 72 hours of receipt of the claim.  An urgent care claim is any claim for treatment with respect to which the application of the time periods for making non-urgent care determinations could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function, or, in the opinion of a physician with knowledge of the claimant’s medical condition, would subject the claimant to severe pain that cannot be adequately managed. If the claim does not contain sufficient information to determine whether, or to what extent, benefits are covered, you will be notified within 24 hours after receipt of your claim of the information necessary to complete the claim.  You will then have 48 hours to provide the information and will be notified of the decision within 48 hours of receipt of the information. You have the right to request an urgent appeal of an adverse benefit determination if you request coverage of a claim that is urgent.  Urgent appeal requests may be oral or written.  You or your physician may call 888-863-8578 or send a written fax to:

OptumRx Member Services
P.O. Box 3410
Lisle, IL 60532-8410
Fax:  1-866-511-2202
Phone:  1-888-863-8578

In the case of an urgent appeal for coverage involving urgent care, you will be notified of the benefit determination within 72 hours of receipt of the claim. This coverage decision is final and binding. You have the right to receive, upon request and at no charge, the information used to review your appeal. You also have the right to bring a civil action under section 502(a) of ERISA if your final appeal denied.