An appeal or "redetermination" is any of the procedures that deal with the review of an unfavorable coverage determination. You should file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.
You can also Contact Us to get the aggregate numbers of grievances, appeals and exceptions filed with us; to question processes; or to ask about the status of a previously submitted grievance, appeal or exception.
Effective January 1, 2022, the contact information for Part D Appeals and Grievances will change as follows.
To start your appeal, a member, prescriber, or a member's appointed representative must contact us within 60 calendar days of the date of the denial notice they received (unless the filing window is extended). You, your prescriber, or your appointed representative may ask for an expedited (fast) or standard appeal via any of the following ways:
Phone:
Contact customer service for any requests including making an oral request to Coverage Determination and Appeals. Our customer service team is available 24/7/365 at 1-844-786-6762 (TTY: 711). Appeals calls are then redirected to the correct department for further action. Other means of contact are provided below.
Fax: 1-855-633-7673
Online: Request for a Redetermination of a Denial of Prescription Drug Coverage
Mail:
CVS Caremark Coverage Determinations/Exceptions
P.O. Box 52000
Phoenix, AZ 85072-2000
You can also contact Medicare directly at 1-800-MEDICARE or file a complaint online at: www.Medicare.gov/MedicareComplaintForm/home.aspx
For an Expedited Appeal: Be sure to ask for a "fast or expedited review." This means you are asking us to give you an answer using the expedited deadlines rather than the standard deadlines. You can request an expedited (fast) appeal for cases that involve prescription drug coverage determinations if you or your doctor believes that your health could be seriously harmed by waiting up to 7 days for a decision. If your request to expedite is granted, we must make a decision no later than 72 hours after receiving your appeal.
For your convenience, you can also use our online form to electronically request your appeal. Please see the Pharmacy Forms section of this website.
For more information about your appeal rights, refer to the Evidence of Coverage, or visit the Contact Us page of this website.
GRIEVANCES
The grievance process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Here are examples of the kinds of problems handled by the grievance process.
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Grievance
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Example
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Respecting your privacy
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- Do you believe that someone did not respect your right to privacy or shared information about you that you feel should be confidential?
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Disrespect, poor customer service, or other negative behaviors
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- Has someone been rude or disrespectful to you?
- Are you unhappy with how our Member or Customer Service has treated you?
- Do you feel you are being encouraged to leave the plan?
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Information you get from us
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- Do you believe we have not given you a notice that we are required to give?
- Do you think written information we have given you is hard to understand?
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Timeliness
(These types of grievances are all related to the timeliness of our actions related to coverage decisions and appeals)
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If you are asking for a decision or making an appeal, you use that process, not the grievance process. However, if you have already asked us for a coverage decision or made an appeal, and you think that we are not responding quickly enough, you can also make a grievance about our slowness. Here are examples:
- If you have asked us to give you a “fast coverage decision” or a “fast appeal, and we have said we will not, you can make a grievance.
- If you believe we are not meeting the deadlines for giving you a coverage decision or an answer to an appeal you have made, you can make a grievance.
- When we do not give you a decision on time, we are required to forward your case to the Independent Review Organization. If we do not do that within the required deadline, you can make a grievance.
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Effective January 1, 2022 to file a grievance you can do the following:
Phone:
Contact customer service for any requests including making an oral request to Coverage Determination and Appeals. Our customer service team is available 24/7/365 at 1-844-786-6762 (TTY: 711). Other means of contact are provided below.
Fax: 1-866-217-3353
Mail:
Grievance Department
P.O. Box 30016
Pittsburgh, PA 15222-0330
You can also contact Medicare directly at 1-800-MEDICARE or file a complaint online at: www.Medicare.gov/MedicareComplaintForm/home.aspx
The grievance must be submitted within 60 days of the event or incident. We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your grievance. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. If we do not accept your grievance in the whole or in part, our written decision will explain why it was not accepted and will tell you about any dispute resolution options you may have.
How to appoint someone to act on your behalf
You or your physician may request an initial determination or file a grievance or appeal. You may name a relative, friend, advocate, doctor or anyone else as your “appointed representative” to act for you. You may already have a representative authorized under State law to act for you; however, if you want someone to act for you, you and your representative must sign and date a statement giving the person legal permission to be your appointed representative. The form is available below. Please contact your plan for more information.
Appointment of Representative Form