Coverage Determination & Exceptions Process

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There are several ways to request a coverage determination or an exception.

You may call our Medicare Clinical PA Department toll-free at (800) 311-0594. Our representatives are available to take your verbal requests Monday through Friday 8:00am - 9:00pm Eastern Time.

You may fax a written request to our Medicare Clinical PA Department at (800) 373-1266.

You may send a written request via US Mail to CVS Caremark Corporation, Medicare Clinical PA Department, P.O. Box 519, Lincoln, RI 02865.

Click here for printable forms.

Initial decisions or coverage determinations
The “initial decision” made by Prescription Pathway is the starting point for dealing with requests a member may have about covering or paying for a Part D prescription drug. If a member’s doctor or pharmacist says that a certain prescription drug is not covered, the member should contact Prescription Pathway and ask us for an initial coverage decision.

With this decision, we explain whether we will provide the requested prescription drug or pay for a prescription drug the member has already received. (This “initial decision” is sometimes called a “coverage determination.”) If our initial decision is to deny the request (this is sometimes called an “adverse coverage determination”), the member can “appeal” the decision by going on to Appeal Level 1 (see Appeals section). If we fail to make a timely “initial decision” on the request, it will be automatically forwarded to the independent review entity for review (see Appeals section).

•	The member asks us to pay for a prescription drug the member has already received; this is a request for an “initial decision” about payment. The member asks for a Part D drug that is not on the plan's list of covered drugs (called a "formulary"), this is a request for a "formulary exception." A "formulary exception" is a type of "initial decision."
•	A member can ask for an exception to our plan’s utilization management techniques. These are also considered to be requests for “formulary exceptions,” and are a type of “initial decision.”
•	A member asks for a non-preferred Part D drug at the preferred cost level, this is a request for a "tiering exception." A "tiering exception" is a type of "initial decision."
•	A member asks for reimbursement for a purchase made from an out-of-network pharmacy. In certain circumstances, out-of-network purchases, including drugs provided in a physician’s office, will be covered by the plan.

When we make an “initial decision,” we are giving our interpretation of how the Part D prescription drug benefits that are covered for members of Prescription Pathway apply in a specific situation.

Who may ask for an “initial decision” about a Part D benefit or payment?
A Prescription Pathway member, or his or her prescribing physician, or someone else the member may name can ask us for an initial decision. The person would be the member’s appointed representative. A member can name a relative, friend, advocate, doctor, or anyone else to act on the member’s behalf. Some other persons may already be authorized under State law to act for the member. If a member wants someone to act on his/her behalf, then that person must sign and date a statement that gives the person legal permission to act as the member’s appointed representative. This statement, or our Appointed Representative Form, must be sent to us at CVS Caremark Corporation, 695 George Washington Highway, Lincoln, RI, 02865, Attention: Privacy Office.

“Initial decision” vs. “making an appeal.”
Whenever a Prescription Pathway member asks for a Part D benefit, the first step is called an “initial decision” or a “coverage determination.” Coverage determinations can be faxed to (800) 373-1266 or submitted in writing to CVS Caremark Corporation, Medicare Clinical PA Department, P.O. Box 519, Lincoln, RI, 02865. Members may use Medicare's Coverage Determination Request Form.

If the member is unhappy with the initial decision, the member can ask for an appeal, which is called a redetermination. Members may send Medicare's Redetermination Request Form to CVS Caremark Corporation, Medicare Clinical PA Department, P.O. Box 519, Lincoln, RI, 02865, or fax to (800) 373-1266. There are also four other levels of appeal that a member may request. See the Appeals section for “how to file an appeal.”

You are entitled to obtain an aggregate number of grievances, appeals, and exceptions filed with Prescription Pathway. You may do so by filing a written request with Prescription Pathway to Prescription Pathway Grievance Department, 1001 Heathrow Park Lane, Suite 5001, Lake Mary, FL 32746.

Last updated: 01/08/2008