Senior Life (PACE)
Coverage Determinations and Exceptions
When ArchCare Senior Life (PACE) receives a request for payment or to provide a drug to a member, it must determine whether the requested prescription drug is necessary and appropriate. 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. 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.
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 Tue, 01/29/2019 – 16:16
Participants may be fully and personally liable for the costs of unauthorized or out-of-PACE program agreement services.
The information contained on this ArchCare website is provided as a community service. It is provided as an educational resource and should not take the place of the advice and recommendations of your personal physician. If you have or suspect you have a health problem, please visit a healthcare professional.
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.
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