Coverage Determination/Redetermination Process

Requesting a Part D Coverage Determination or Redetermination (Appeal)

A coverage determination is an initial decision about your Medicare Part D prescription drug coverage. You may ask whether a drug is covered, whether certain coverage requirements apply, whether you can be reimbursed for a prescription drug you already purchased, or whether an exception can be made to the plan’s coverage rules. If your request is denied, you have the right to ask for a redetermination, also known as an appeal.

If you are requesting an exception, your doctor or other prescribing provider will need to explain the medical reasons the exception is needed. Including supporting medical information when the request is submitted may help us reach a decision more quickly.

Submit Your Request Online

CVS Caremark manages online coverage determination and appeal requests through CoverMyMeds. If you choose to submit your request online, you will be redirected to CoverMyMeds, where you may be asked to sign in to an existing account or create a new account before completing your request.

To begin a coverage determination request, visit:
Start a Coverage Determination Request

Information about appeal and claim review options is available at:
Learn About Appeal and Claim Review Options

Speak With a Representative

If you have questions about the coverage determination or appeal process, or would like assistance understanding your options, call us at (833) 843-0559 (TTY: 711), Monday through Friday from 8:00 a.m. to 8:00 p.m.

Submit a Request by Mail or Fax

If you prefer not to use the online process, you may submit your request by mail or fax.

Mail:
CVS Caremark Appeals Department MC109
PO Box 52000
Phoenix, AZ 85072-2000

Fax:
(855) 633-7673

Before submitting a request, you may find the following resources helpful.
Prescription Drug Prior Authorization and Step Therapy Exception Request Form
CMS Information About Part D Coverage Determinations and Appeals

The CMS resource explains how Part D coverage determinations and appeals work, outlines member rights, and provides access to applicable request forms and instructions.

For additional information about the Part D coverage determination and appeals process, please refer to Chapter 9 of your Evidence of Coverage.