If we make a coverage decision and you are not satisfied with this decision, you can appeal the decision. An appeal is a formal way of asking the plan to review and change a coverage decision we have made. When you make an appeal, we review the coverage decision to check if we were following all of the rules properly. Your appeal is handled by different reviewers than those who make the original decision. When we have completed the review, we give you our decision.
If you wish, you can appoint someone to act for you and communicate with us on your behalf about your benefits and your appeal. This can be a relative, friend, a healthcare professional or lawyer, or any other person or organization you want to represent you. To do so, you must complete, sign and send us an Appointment of Representative form that gives that person or organization permission to speak with us and make decisions for you.
HOW TO MAKE AN APPEAL
To start your appeal, you, your doctor or your representative must contact our plan. If you are asking for a standard appeal, make your appeal by submitting a written request. If you are asking for a “fast appeal,” you may make your appeal in writing or by calling us at the number listed below. You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you of our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.
If your health requires it, ask for a “fast appeal.” If we are using the fast deadlines, we will give you our answer within 72 hours after we receive your prescription drug appeal. We will give you our answer sooner if your health requires it.
If we are using the standard deadlines, we will give you our answer within seven calendar days after we receive your prescription drug appeal . We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so. If you believe your health requires it, you should ask for “fast appeal.” In some cases, such as when additional information is needed and it is in your best interest to extend the time frame of our response, we may extend the time up to 14 days. If we extend the time, you will receive notification from the plan.
There are four ways to file an appeal for prescription drug determinations:
- By phone: To request a fast appeal, call 1‑855‑344‑0930 (TTY/TDD: 711) 24 hours a day, seven days a week
- By mail: If you wish to file a standard appeal, you must send written request within sixty (60) days from the date of the notice of coverage determination to: CVS Caremark Part D Services Appeals, MC109, PO Box 52000, Phoenix, AZ 85072-2000.
- By fax: Fax the completed Redetermination Request Form within sixty (60) days from the date of the notice of coverage determination to 1‑855‑633‑7673.
- Online: Within sixty (60) days from the date of the notice of coverage determination, you may submit a Redetermination Request Form online.
You can download the Redetermination Request Form to use for your appeal.