Coverage Determination, Appeals and Grievances
Coverage Determination
A decision CareFirst BlueCross BlueShield Advantage DualPrime makes about your benefit and coverage and the amount you will pay. If a drug is not covered or there are restrictions or limits on a drug, you may request a Coverage Determination.
Exception requests are granted when we determine that a requested drug is medically necessary for you. Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You may contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request.
Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
- If request is approved, a notice is sent to the provider and member.
- If request is denied, a notice is sent to the provider and member explaining the reason why the request was denied and information on how to submit a redetermination (Appeal).
How to Request a Coverage Determination
A member, prescriber, or a member's appointed representative may request a standard or expedited coverage determination. You, your prescriber or your appointed representative may request a coverage decision and/or exception any of the following ways:
Phone
Contact customer service for any requests including making an oral request related to Coverage Determination and Appeals. Our customer service team is available at 844-786-6762, 24 hours a day, 7 days a week (TTY: 711). Appeals calls are then redirected to the correct department for further action.
Fax
855-633-7673
Online
CVS Caremark Coverage Determinations/Exceptions
P.O. Box 52000
Phoenix, AZ 85072-2000
You can also contact Medicare directly at 1-800-MEDICARE or file a complaint online at: Medicare.gov
Appeal
How to Request a Redetermination (Appeal)
An initial coverage determination decision can be appealed. To start your appeal, a member, prescriber, or a member's appointed representative must contact us within 60 calendar days of the date of the denial notice they received (unless the filing window is extended). You, your prescriber, or your appointed representative may ask for an expedited (fast) or standard appeal via any of the following ways:
Phone
Contact customer service for any requests related including making an oral request to Coverage Determination and Appeals. Our customer service team is available at 844-786-6762, 24 hours a day, 7 days a week (TTY: 711). Appeals calls are then redirected to the correct department for further action.
Fax
855-633-7673
Online
Redetermination Form English | Spanish
CVS Caremark Coverage Determinations/Exceptions
P.O. Box 52000
Phoenix, AZ 85072-2000
You can also contact Medicare directly at 1-800-MEDICARE or file a complaint online at: Medicare.gov
Grievance
A “grievance” is a complaint that does not involve a coverage determination. The grievance process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive.
How to Request a Grievance
Phone
Contact our customer service team at 844-786-6762, 24 hours a day, 7 days a week (TTY: 711). Appeals calls are then redirected to the correct department for further action.
Fax
856-217-3353
Grievance Department
P.O. Box 30016
Pittsburgh, PA 15222-0330
You can also contact Medicare directly at 1-800-MEDICARE or file a complaint online at: Medicare.gov