Coverage Determinations and Exceptions PACE | ArchCare
archcare gala
English Chinese (Simplified) Chinese (Traditional) Spanish

Change text size: A A A

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.

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.

Appointment of Representative Form – English
Appointment of Representative Form – Spanish

 


H4393_2016website

Learn More

I am interested in ArchCare services and would like more information.

ArchCare offers a continuum of care to meet your healthcare needs.

Your privacy is important to us. Read our Privacy Policy

Please note that by clicking “Request Information,” I expressly

give permission for a sales agent from an ArchCare Medicare

or Medicaid plan to contact me.