Coverage Determinations

Coverage determinations/exceptions, appeals, and grievances

There are many ways you can request a review or appeal made about your care or the behavior of those providing your care. These take the form of coverage determinations including exceptions, appeals, and grievances.

Coverage determinations are decisions we make about your benefits and coverage or about the amount we will pay for your prescription drugs covered under the Part D benefit included in your plan.

Below are examples of coverage determination exceptions you may ask us to make for your Part D drugs:

  • covering a Part D drug that is not on the plan's List of Covered Drugs (Formulary)
  • waiving a restriction on the plan's coverage for a drug (such as limits on the amount of the drug you can get)
  • paying a lower cost-sharing amount for a covered drug on a higher cost-sharing tier
  • asking whether a drug is covered for you and whether you satisfy any applicable coverage rules
    • For example, when your drug is on the plan's list of covered drugs (Formulary) but we require you to get approval from us before we will cover it for you.
  • asking us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment

Please review your Evidence of Coverage for details.

Appeals, also called Redeterminations, are a formal way of asking us to review and change a coverage decision we have made. There are five levels of appeals you can make if any part of a request for a coverage determination is denied. Instructions on how to appeal are included if you receive a denial on a coverage determination decision letter or you can call us at 1-877-853-7693.

Coverage Determinations (Including Exceptions), Appeals, and Grievances and Details

Requesting a coverage determination can be done by online form, phone, mail or fax.

Forms: Instructions and forms (online or PDF download) for requesting a drug coverage determination or exception are in the documents section. Or, you or your provider can use Medicare's standard forms for coverage determinations and appeals found on the CMS website and use the Request for Medicare Prescription Drug Determination Request Form.

About mailing forms: Send mailed forms to the address below. You don't have to have all the information complete on the form before submitting, however, all information will need to be completed for a timely decision.

Coverage determinations and appeals about prescription drugs can be sent to:

Blue MedicareRx (PDP)
CVS Caremark
P.O. Box 52000, MC109
Phoenix, AZ 85072-2000
Phone: 1-888-648-9622
Fax: 1-855-633-7673

Requesting Summary Information

If you want to obtain additional information on coverage determinations, appeals, and grievances that you have filed with the plan, please call Customer Service or send a written request for this information to:

Blue MedicareRx (PDP)
P.O. Box 4229
Scranton, PA 18505
Phone: 1-877-853-7693
Fax: 1-855-874-4712

Grievances

Grievances are where you express dissatisfaction that don't involve a coverage determination. They involve problems related to coverage or payment for care, such as the quality of care, customer service, waiting times, getting appointments and so on. If you have a grievance, call customer service at 1-877-853-7693 or send to the address below. You can also file a complaint directly with Medicare by calling 1-800-Medicare.

Grievances can be sent to:

Blue MedicareRx Arizona
Attn: Grievance Unit
P.O. Box 4347
Scranton, PA 18505
Fax: 1-855-874-4712

For more information

If you have questions about coverage determinations, appeals, or grievances, call customer service at 1-877-853-7693 for Blue MedicareRx (TTY hearing impaired users call 711), 8 a.m. to 8 p.m., daily, local time.

For more information on coverage determinations, exceptions, grievances and appeals, see Chapter 7 of your Evidence of Coverage if you're a member of Blue MedicareRx.

Appointing a representative

You can appoint someone to help you with coverage determinations or appeals at any time by completing the Appointment of Representative form in the documents section, or on Medicare’s website. Instructions for completing the form are on the back. When complete, mail or fax it to:

Blue MedicareRx (PDP)
CVS Caremark
P.O. Box 52000, MC109
Phoenix, AZ 85072-2000
Fax: 1-855-633-7673

If you need help with any of the forms or requests, please call Customer Service. They will answer any questions you may have and help you with the appropriate forms. You can call Blue MedicareRx customer service at 1-877-853-7693 8 a.m. to 8 p.m., daily, local time. TTY hearing impaired users should call 711.