Part D Coverage Determinations, Exceptions, Grievances, and Appeals

This section contains information on your rights to submit appeals, request coverage determinations, or file complaints.

 

As a plan member, federal law guarantees your right to make complaints if you're in any way dissatisfied with a part of your coverage. Medicare has established a variety of rules around how members should file complaints and how Clover must process them. If you file a complaint, we must process it fairly. You can't be dis-enrolled or penalized in any way for making a complaint.

Depending on the subject, a complaint will either be handled as a coverage determination, an appeal, or a grievance. To obtain an aggregate number of grievances, appeals, and exceptions filed with Clover, contact us at:

PPO plans: 1-855-479-3657 
HMO plans: 1-844-232-2316 

 

What's a coverage determination?

A coverage determination is the first decision we make about covering a drug you've requested. If your doctor or pharmacist tells you a certain prescription drug isn't covered, you may contact us to request a coverage determination.

 

What's an exception?

An exception is a type of coverage determination. You may ask us to make exceptions to our coverage rules in a variety of different situations.

 

How do I request an exception?

First, ask your prescribing doctor to contact us at:

CVS Caremark
Attention – Prior Authorization – Part D
P.O. Box 52000, MC109
Phoenix, AZ 85072-2000

PPO plans: 1-855-479-3657 
HMO plans: 1-844-232-2316



Fax: 1-855-633-7673
Speech and hearing impaired call: 1-866-236-1069 (TTY 711)

Remember your doctor must submit a statement supporting your request. This statement must indicate that the requested drug is medically necessary for treating your condition because no other covered drug would be as effective, or alternate medications would have adverse effects on you. If the exception involves a pre-authorization, quantity limit, or another limit we've placed on that drug, the doctor’s statement must also indicate that the pre-authorization or limit wouldn't be appropriate given your condition, or would have adverse effects on you.

Once the physician’s statement is submitted, if it was expedited, we'll notify you of our decision within 24 hours. If the exception was a standard request, we'll make a decision within 72 hours. Your request will be expedited if we determine—or your doctor informs us—that your life, health, or ability to regain maximum function may be seriously jeopardized by awaiting a standard request.

 

What's an appeal?

If we issue an unfavorable coverage determination you'd like us to reconsider, you may file an appeal known as a "redetermination." And if our decision about that redetermination is also unfavorable, you have additional appeal rights.

 

How do I request an appeal?

If your request is denied, you have the right to appeal by asking for a review of the prior decision. You must request this appeal within 60 calendar days from the date of our first decision. We accept standard and expedited requests by phone and in writing. To complete this process, ask your prescribing doctor to contact us at:

CVS Caremark
Attn: Part D Appeals
P.O. Box 52000, MC109
Phoenix, AZ 82072-2000

PPO plans: 1-855-479-3657 
HMO plans: 1-844-232-2316 

 

Fax: 1-855-633-7673
Speech and hearing impaired call: 1-866-236-1069 (TTY 711)

 

What's a grievance?

A grievance is any complaint other than those involving coverage determinations. You may file a grievance if you’re in any way dissatisfied with Clover or with one of our network pharmacies, so long as the pharmacy grievance isn’t related to coverage for a specific prescription drug.

To file a grievance, you or your representative may contact us at:

CVS Caremark Grievance
Medicare Part D Grievances Department
P.O. Box 30016
Pittsburgh, PA 15222-0330

PPO plans: 1-855-479-3657 
HMO plans: 1-844-232-2316 


Fax: 1-866-217-3353
Speech and hearing impaired call: 1-866-236-1069 (TTY 711)

If you need assistance in requesting an exception, appeal, or grievance, please call Clover:

PPO plans: 1-855-479-3657 (TTY 711), 8am-8pm local time, 7 days a week. *
HMO plans: 1-844-232-2316 (TTY 711), 8am-8pm local time, 7 days a week. * 

 

Resources

 

Request forms

 

CMS Part D prescription drug appeals