Part D Coverage Determinations, Exceptions, Grievances, and Appeals

 

What's a coverage determination?

A coverage determination is the first decision we make about covering a drug you've requested. If you are informed a certain prescription drug isn't covered, you may contact us to request a coverage determination.  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, such as formulary exceptions, prior authorizations, quantity limits, and tier exceptions.

How do I request a coverage determination or 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

• Online: Coverage Determination Form
• PPO plans: 1-855-479-3657
• HMO plans: 1-844-232-2316
• Fax: 1-855-633-7673
• Speech and hearing impaired call: (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.

What happens next? 

Once the physician’s statement is submitted, we'll notify you of our decision within 24 hours for expedited requests. 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.  If the exception was a standard request, we'll make a decision within 72 hours.

You can also check your coverage determination status online. Sign in to the Clover Member Portal and then click on the Prescription Web Portal by Caremark. 

What's an appeal?

If we deny coverage for a drug, you can ask us to look at our decision again. This is called a 'redetermination' or appeal. If we still deny it after that, you have more appeal options.

What's a grievance?

A grievance is a complaint about anything other than a decision about drug coverage. You can file a grievance if you're unhappy with Clover, one of our pharmacies, or prescription drug service.

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

CVS Caremark Medicare Part D - Grievances

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: (TTY 711)

We strive to provide excellent service and medications needed to stay healthy.  As a member, you have the right to complain if you're not satisfied with your coverage. Medicare has rules for how you should file complaints and how Clover Health must handle them. We will process your complaint fairly, and you won't be penalized for making one. Your complaint will be handled as a coverage determination, appeal, or grievance, depending on what it's about. To find out the total number of complaints, appeals, and exceptions filed with Clover Health, contact us at:

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