What do I need to know about coverage determinations?

When CVS Caremark receives a request for payment or to provide a Part D drug to a member, CVS Caremark must determine whether or not the request is necessary and appropriate and what your part of the cost is for the drug. These actions by CVS Caremark are known as “coverage determinations.”

Coverage determinations include exception requests. You have the right to ask us for an “exception” if you believe you need a drug that is not on our list of covered drugs (formulary), or believe you should get a drug at a lower copay.

Before you request a drug determination, please call Member Services at 1-888-260-1010, 24 hours a day, 7 days a week, TTY/TDD members 1-866-236-1069 and ask if your drug is covered. 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 the affected member within 72 hours of receiving the request, or sooner if their health condition requires more immediate action. If immediate action is necessary, you or your physician can request that we review your situation in 24 hours.

We accept request for a coverage determination by mail, email, phone, or fax.

Note: Often CVS Caremark will not have all of the information it needs to make a coverage determination. In those cases, an extra 2 weeks is allowed to gather all necessary supporting documentation. In addition, if we approve your exception request for a non-formulary drug, you cannot request an exception to the copay you must pay for the drug. 

> Part D Coverage Determination Request Form (English / Español)

The Part D Coverage Determination form is also available by visiting the CMS website.
* Please note that clicking on this link will take you away from the Healthfirst website.