What is an appeal?
Once CVS Caremark notifies you of a coverage determination decision, you may or may not agree with it. You (or your authorized representative) can ask us to reconsider our decision. This is known as filing an appeal. There is a fast track and routine process for handling appeals similar to coverage determination requests.
The information below explains how these different time frames work.
You have a right to appeal if you think CVS Caremark:
- Decided not to cover a drug, vaccine, or other Part D benefit;
- Decided not to reimburse you for a Part D drug that you paid for;
- Reimbursed you less than you feel you should have received;
- Asks you to pay a different cost-sharing amount than you think you are required to pay for a prescription;
- Denied your exception request;
- Made a coverage determination you disagree with.
CVS Caremark will consider your appeal thoroughly and promptly. It is important to let CVS Caremark know as soon as possible that you wish to file an appeal. We accept request for a redetermination in any format. If you wish to file a regular appeal (also called a "standard appeal"), you may complete a Request for Redetermination of Medicare Prescription Drug Denial Form and send your request within sixty (60) days from the date of the notice of coverage determination from CVS Caremark to:
CVS Caremark Part D Services
P.O. Box 52000
Phoenix, AZ 85072-2000
To request a fast appeal, you may call Member Services at 1-888-260-1010, or TTY 1-888-542-3821 for the hearing or speech impaired, 24 hours a day, 7 days a week.
If you are concerned about the quality of care you have received (for example, you believe our pharmacist provided you with the incorrect dose of a prescription), you may also file a complaint with Island Peer Review Organization (IPRO), at 1-516-326-7767 or TTY 1-516-326-6182 the State's Quality Improvement Organizations, or QIO, which is a group of doctors and health professionals who monitor the quality of care given to Medicare beneficiaries. The QIO review process is designed to help stop any improper medical practices.