Part D Appeals & Grievances

  • There are times when you may have a problem or concern regarding your Part D (prescription drug coverage). The following will help you with that process.

    Coverage determinations

    Coverage determinations are the first decisions made by the plan that determine whether to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exception requests.

    "Standard" Coverage Determination: the decision will typically be made within a 72-hour timeframe.

    "Fast" or "Expedited" Coverage Determination: ONLY available if you or your doctor determine that waiting for a standard decision could seriously harm your health or your ability to function. “Fast" decisions only apply for Part D drugs that you have not yet received. A fast coverage determination is made typically within 24 hours.

    Appeals and when to use one

    An appeal is the process that deals with the review of an unfavorable coverage determination. You can file an appeal if you want us to reconsider a decision we have made regarding you Part D prescription drug benefits or cost sharing associated with you Part D drug coverage.

    A "standard" appeal decision means we have up to 7 calendar days from the time we receive your request to decide.

    A "fast" appeal decision means an appeal decision for a Part D drug you have not received may take up to 72 hours from the time we receive your request.

    How do I check status or request a coverage determination, exception or appeal?

    To check status or to request a "Standard," "Fast," or "Expedited" coverage determination or appeal: You, your appointed representative, or your prescribing physician should contact us by telephone, fax, or mail at the numbers or address below:

    Call: 844-449-4723 (TTY/TDD: 711)
    Fax: 855-633-7673

    Write:
    CVS Caremark Part D Appeals and Exceptions
    PO Box 52000, MC109
    Phoenix, AZ, 85072-2000

    You, your prescriber, or member representative may ask for a coverage decision electronically by completing our secure, online Medicare Coverage Determination Form.

    You can also make this request by completing the Prescription Drug Coverage Determination Form and faxing or mailing it to us.

    Grievance and when to use one

    A grievance is any complaint or dispute (dissatisfaction) other than one involving an organization determination. It is different from a coverage determination request; it usually will not involve coverage or payment for Part D drug benefits. Grievance decisions will be made as quickly as your case requires but no later than 30 calendar days after receiving your complaint. If you request a "fast" grievance, a decision will be rendered within 24 hours.

    How do I check status or request a grievance?

    To check status or to file a grievance: You or your appointed representative should contact us by telephone or mail to the address below:

    Call: 888-850-8526 (TTY/TDD: 711)

    April 1 – September 30, Monday to Friday, 8 a.m. to 8 p.m.

    October 1 – March 31, 7 days a week, 8 a.m. to 8 p.m.

    Mail:
    Premera Blue Cross Medicare Advantage Plans
    Attn: Appeals and Grievances Department
    PO Box 262527
    Plano, TX 75026

    For more about your plan's grievance, determination, and appeals process:

    Refer to chapter 9 of your plan's Evidence of Coverage (EOC) for more information regarding grievance, determination, and appeals processes.