Part D: Coverage Determinations, Exceptions, Appeals, and Grievances
This section contains information on your rights as a Clover member to submit appeals, request coverage determinations, or file complaints in relation to Part D coverage.
Coverage Determination
An initial determination on whether we will grant an exception to cover a requested drug that is not currently on our formulary.
Appeal
A request that the plan review a denied coverage determination.
Grievance
A type of complaint you make about our plan, providers, or pharmacies, including a complaint concerning the quality of your care. This doesn’t involve coverage or payment disputes.
As a plan member, federal law guarantees your right to take these steps if you're in any way dissatisfied with a part of your coverage. If you file a complaint, we must process it fairly. You can't be disenrolled or penalized in any way for making a complaint.
You can have an authorized representative—like a trusted friend or family member—make some of these requests for you. To do so, include this Authorized Representative Form with your appeal, grievance, or prior authorization.
Coverage Determination
If you are informed a prescription drug isn't covered, you may request a coverage determination to see if we'll cover the drug and make an exception to our normal rules. You might request an exception for reasons such as coverage on the formulary, prior authorization requirements, quantity limitations, or the copay tier level.
How do I ask for a coverage determination?
In order to process a coverage determination based on an exception request, you’ll need a statement from your doctor. 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 requested exception involves a prior authorization, quantity limit, or another limit we've placed on that drug, the doctor’s statement must also indicate that the prior authorization or limit wouldn't be appropriate given your condition, or would have adverse effects on you.
Complete the Coverage Determination Form online. Or, you can call us at 1-855-479-3657 (TTY 711) for PPO plans and 1-844-232-2316 (TTY 711) for HMO plans. Alternatively, complete the Coverage Determination Request Form for PPO plans or the Coverage Determination Request form for HMO plans and mail it to:
Attention: Prior Authorization Part D
CVS Caremark
P.O. Box 52000, MC109
Phoenix, AZ 85072-2000
What happens next?
Once the doctor’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.
Appeal
If we deny your coverage determination request, 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.
How do I request an appeal?
You must request an appeal within 65 calendar days from the date of our first decision. We accept standard and expedited requests by phone and in writing. The best way to complete this process is to ask your prescribing doctor to contact us. To submit an appeal, complete the Coverage Redetermination Form online. Or, call us at 1-855-479-3657 (TTY 711) for PPO plans and 1-844-232-2316 (TTY 711) for HMO plans.
What if I disagree with the decision on my appeal?
If your appeal request is denied, you have the right to a Level 2 Appeal. This is also called a ‘reconsideration’ from an independent review organization within 65 calendar days from the date of Clover Health’s appeal decision. To initiate a reconsideration, complete the C2C Innovative Solutions, Inc. online questionnaire. Or, call C2C Innovative Solutions, Inc. at 1-833-919-0198 (TTY 711).
Grievance (Complaint)
A grievance is a type of complaint you make about our plan, providers, or pharmacies, including a complaint concerning the quality of your care. This doesn’t involve coverage or payment disputes. For grievances about drug coverage decisions, begin with a Coverage Determination Request Form.
How do I file a grievance?
To file a grievance, you or your representative may call us at 1-855-479-3657 (TTY 711) for PPO plans and 1-844-232-2316 (TTY 711) for HMO plans. Alternatively, you can write your grievance and send via fax at 1-866-217-3353, or mail to:
Attention: Medicare Part D Grievances
CVS Caremark
P.O. Box 30016
Pittsburgh, PA 15222-0330
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 one of the numbers listed above.
Other Resources
Medicare.gov “Appeals in a Medicare drug plan"