Coverage Determinations and Exceptions | ArchCare
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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.

 


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