If you have a medically necessary need for a non-formulary drug, you can ask us to make an exception and cover the drug. If we deny your exception request, we will mail you a letter explaining why your request was denied. This letter will include how you can appeal our decision. You can ask for a standard or expedited appeal.
- For standard appeals, we must provide a decision no later than seven days after we get your appeal request.
- Ask for an expedited (fast) appeal when you or your doctor believes that your health could be seriously harmed by waiting up to seven days for a decision. We will give you a decision no later than 72 hours after we get you expedited appeal request.
If your prescribing doctor supports your expedited appeal or requests an expedited appeal for you, we automatically grant you a faster decision. If you request an expedited appeal without support from a doctor, we determine whether or not your health situation requires a fast appeal. In the event we determine your situation does not require a fast decision, we give you a decision within 7 days. We will not expedite an appeal for a drug you already receive.
How to request an appeal
- Expedited Appeals: You or your appointed representative should contact us by telephone at 1-855-344-0930, TTY 1-866-236-1069 or fax at 1-855-633-7673.
- Standard Appeals: You or your appointed representative should complete the Prescription Drug Coverage Redetermination Form and mail it to CVS Caremark, Attention: Prior Authorization – Part D, 620 Epsilon Drive, Pittsburgh, PA 15238. You may also fax it to 1-855-633-7673.
We will review your appeal and give you a decision. If we deny your appeal, you can request an outside review by an independent reviewer not associated with our plan.
If you disagree with that decision, you still have the right to appeal further. We will notify you of your appeal rights if this happens.
Our contact information
If you need help with an appeal, call Customer Service at 1-855-479-3661 or TTY 711, 24 hours a day, seven days a week.
- Medicare Rights Center, 1-888-HMO-9050
- 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048