If you have a complaint, dispute or level of dissatisfaction with Pharmacy Benefit Dimensions or one of our affiliated providers, or if you disagree with a coverage decision we have made, you will find assistance here.

Complaints

If you have a grievance, which is any complaint, dispute or level of dissatisfaction you may have with Pharmacy Benefit Dimensions or one of our affiliated providers you may:

Print and fill out the Member Complaint Form and mail, email or fax it to:

Pharmacy Benefit Dimensions
Benefit Administration
511 Farber Lakes Drive
Buffalo, NY 14221
Email: pbdmedicareservicing@pbdrx.com
Fax: (716) 580-5264

Call Member Services at (716) 504-4444 or 1-800-667-5936 (TTY users call 711)
October 1 – March 31: Monday – Sunday, 8 a.m. – 8 p.m. EST
April 1 – September 30: Monday – Friday 8 a.m. – 8 p.m. EST

You may also file a complaint directly with Medicare.

Appeals

An appeal is the type of complaint you make if you disagree with a coverage decision we have made.

To appeal, complete the Appeal Request Form within 65 days of the initial coverage decision and mail or fax it to:

Pharmacy Benefit Dimensions
Benefit Administration
511 Farber Lakes Drive
Buffalo, NY  14221
Fax: (716) 580-5264

Or

Call Member Services at (716) 504-4444 or 1-800-667-5936 (TTY users call 711)
October 1 – March 31: Monday – Sunday, 8 a.m. – 8 p.m. EST
April 1 – September 30: Monday – Friday 8 a.m. – 8 p.m. EST

If you need someone else to file an appeal on your behalf, you will need to fill out an Appointment of Representative Form or provide appropriate legal papers supporting your status as the member’s authorized representative.

Mail, email or fax us this completed form along with the Member Appeal/Complaint Form.

To learn more about how Independent Health manages complaints and appeals, review the Appeals and Quality of Care Complaints Information.

For more information on complaints and appeals please refer to your Evidence of Coverage (EOC) for your Prescription Drug plan.

If you are new to Medicare, or are looking for information on a new Medicare plan or would like to know whether you are eligible for Medicare financial assistance, visiting these sites may help.

Medicare’s Website: You can download a copy of the official Medicare handbook, “Medicare & You,” or request that a copy be sent to you. Visit Medicare’s website.  

Medicare Cost Payment Assistance: These agencies may be able to offer help in paying for your Medicare costs.

•  Erie County Department of Social Services
•  Niagara County Department of Social Services  
•  New York State Office of the Aging
• The Official Website of the U.S. Social Security Administration

Privacy

Please read Pharmacy Benefit Dimensions' Medicare Privacy Notice.

Fraud, Waste and Abuse

Protecting your personal information is the best line of defense in the fight against health care fraud and abuse. Use the following tips to help you identify fraud, waste and abuse and keep your health information safe.

Identity Theft

Take these three steps to keep yourself safe from identity theft:

• Don’t provide your personal information (e.g., your Medicare, Medicaid or Social Security numbers) to anyone except your doctor, health plan or Medicare approved provider. You can check if a provider is Medicare approved by calling 1-800-MEDICARE (1-800-633-4227) (TTY: 711).
• Keep a personal health care journal or calendar to record your doctor visits, tests and procedures.
• Save and review your Medicare Summary Notices and Part D Explanation of Benefits.

Dishonest Practices

Keep a watchful eye out for any doctors or health care providers who:

• Ask for your Medicare number in exchange for free equipment or services, or for “record keeping purposes.”
• Tell you that the more tests that are provided the cheaper they are.
• Advertise “free” consultations to people with Medicare.
• Call or visit you and say they represent Medicare or the federal government – Medicare will not call or visit your home.
• Use telephone or door-to-door selling techniques.
• Use pressure or scare tactics to sell you expensive medical services or diagnostic tests.

Billing Issues

Monitor your billing statements and review your medical records for potential errors, such as:

• Charges for prescriptions or services you didn’t receive.
• Double billing for the same prescription or service.
• Ask your provider whenever you:
  • Don’t understand your billing statement.
  • Are not sure if you received a service that is listed.
  • Feel a service your provider is recommending is unnecessary.

Suspect Fraud, Waste or Abuse?

Make a confidential report by contacting Independent Health’s Special Investigations Unit (SIU) at 1-800-665-1182 (TTY: 711) from 8:30 a.m. – 3 p.m. Monday – Friday

• Or by e-mail at: SIU@independenthealth.com
• Or contact Medicare at: 1-800-633-4227 (TTY: 711)

Pharmacy Benefit Dimensions' Responsibilities

Upon your (member) disenrollment from the plan, Pharmacy Benefit Dimensions must:

• Provide you with an acknowledgement and confirmation of disenrollment notice.
• Provide you with a denial of or rejection by CMS of disenrollment, if applicable.
• Inform you about Medigap rights during a special enrollment period.
• Provide advance notice in the event you are involuntarily disenrolled and explain reasons for disenrollment.
• Provide advance notice in the event your enrollment in a Prescription Drug Plan is ending.

Pharmacy Benefit Dimensions must end your membership if any of the following happen:

• If you do not stay continuously enrolled in Medicare Part A & Part B.
• If you move out of our service area.
• If you are away from our service area for more than six months in a row.
  • If you move or take a long trip, you need to call Member Services to find out if the place you are moving or traveling to is in our plan’s area. (Phone numbers for Member Services are located in the right column.)
• If you have been a member of our plan continuously since before January 1999 and you were living outside of our service area before January 1999, you may continue your membership. However, if you move and your move is to another location that is outside of our service area, you will be disenrolled from our plan.
• If you become incarcerated (go to prison).
• If you lie about or withhold information about other insurance you have that provides prescription drug coverage.
• If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)
• If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)
• If you let someone else use your membership card to get medical care. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.) If we end your membership because of this reason, Medicare may have your case investigated by the Inspector General.
• If you do not pay the plan premiums for 90 days. We must notify you in writing that you have 90 days to pay the plan premium before we end your membership.
• If you are required to pay the extra Part D amount because of your income and you do not pay it, Medicare will disenroll you from our plan and you will lose prescription drug coverage.

If you are leaving our plan, you must continue to get your medical care through our plan until your membership ends.

Member Responsibilities

• You must make a written request for disenrollment prior to the 1st of the month in which disenrollment is intended.
• Please contact your group administrator to understand when you may be able to disenroll from your plan.

Member Notifications

• You will be advised that upon disenrollment from a Part D plan, that unless you obtain another Part D plan, or otherwise elect another type of creditable prescription drug coverage, that you may be subject to a Late Enrollment Penalty should a lapse in coverage occur for 63 or more days.
• You will be reminded that if you do not enroll in another Medicare Advantage Plan or Medicare Advantage Plan with Prescription Drug coverage, that you will be enrolled in Original Medicare.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

To request an exception, please call our Member Services Department or send us a Drug Coverage Determination / Exception Form.

You can appeal that decision by completing and sending our Drug Coverage Redetermination Form.

Both forms can be sent by:

Mail:
Pharmacy Benefit Dimensions
Pharmacy Department
511 Farber Lakes Drive
Buffalo, New York  14221

Fax: (716) 580-5264

E-mail: pbdmedicareservicing@pbdrx.com
Note: Either attach a completed form to the e-mail or you may provide the Determination or Redetermination details in the e-mail body.

Pharmacy Benefit Dimensions is a subsidiary of Independent Health. Independent Health is a PDP with a Medicare contract. Enrollment in Pharmacy Benefit Dimensions PDP depends on contract renewal between Independent Health and CMS.