Part D Coverage Determinations, Exceptions, Grievances, and Appeals

 

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

Online: Coverage Redetermination 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)

If your appeal request is denied, you have the right to a Level 2 Appeal (Reconsideration) with an Independent Review Organization within 60 calendar days from the date of Clover Health’s appeal decision. To request a Reconsideration, you may use the request forms provided on this page.

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 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)

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

Resources

CMS Model Electronic Complaint Form

Request forms

Request for Prescription Drug Coverage Determination

Request for Redetermination of Medicare Prescription Drug Denial

2024 Request for Reconsideration of Medicare Prescription Drug Denial

CMS Part D prescription drug appeals

How to Submit an Appeal

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