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ArchCare Advantage (I-SNP) Member Resources

Coverage Determinations and Exceptions

When ArchCare Advantage receives a request for payment or to provide a Part D drug to a member, it must determine whether the requested prescription drug is necessary and appropriate and what the member’s share of the cost is for the drug. These actions are called “coverage determinations.”

Coverage determinations include exception requests. You, the member, have the right to ask us for a utilization management exception if you believe you need a drug that is not on our formulary or should get a drug at a lower co-payment. If you request an exception, your doctor must provide a statement to support your request. Once we receive a statement from your doctor, we must make a coverage determination and notify you within 72 hours of receiving the request, or sooner if your health condition requires more immediate action. If immediate action is necessary, you or your physician can request that we review your situation within 24 hours.

To request a coverage determination, you can call 1‑855‑344‑0930, 24 hours a day, seven days a week. TTY users can call 711. You can also fill out the Coverage Determination Request form below and fax it to 1‑855‑633‑7673, or mail it to CVS Caremark Part D Services, MC109, PO Box 52000, Phoenix, AZ 85072-2000.

For further information, please refer to Chapter 9 of the Evidence of Coverage – Coverage Determinations.

Coverage Determination Request Form
Online Coverage Determination Form

You or your appointed representative can request a coverage determination, including for an exception. You can name a relative, friend, advocate, lawyer, doctor or someone else to act for you. Others may already be authorized under state law to act for you. Please fill out the Appointment of Representative form and send it to us with your request.


This page was last updated on Thu, 10/24/2019 – 10:17

ArchCare Advantage HMO SNP is a Coordinated Care Plan with a Medicare contract. Enrollment in ArchCare Advantage depends on contract renewal. The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact ArchCare Advantage. This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care. Limitations, copayments and restrictions may apply. Eligible beneficiaries may enroll in our plan at any time of year. You must continue to pay your Medicare Part B premium. Benefits, formulary, pharmacy network, premium and/ or co-payments/co-insurance may change on January 1 of each year.

This information is available for free in other languages. Please contact our customer service number toll-free at 1-800-373-3177, seven days a week, 8 a.m. – 8 p.m. (TTY/TDD: 711). Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro número de servicio al cliente al 800-373-3177, TTY 711, de domingo a sábado, de 8:00 am-8:00 pm.

Discrimination is Against the Law
ArchCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ArchCare does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1 800-373-3177 (TTY: 711).
注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電1 800-373-3177 (TTY: 711)