Coverage Determinations & Appeals

We're here to help guide you through the drug coverage determination process, including appeals.

There are times when a Generations Advantage plan member may want a certain prescription drug to be covered or paid for when the member's doctor or pharmacist says that it is not covered.

Whenever a Martin's Point Generations Advantage member asks for coverage under the Part D Prescription Drug benefit, the request goes through a coverage determination process.

Asking for a “coverage determination” is the starting point of this process. There is an appeals process available for members who would like to appeal an initial decision or coverage determination. 

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What are initial decisions or coverage determinations?

The "initial decision" (sometimes called a coverage determination) made by Martin's Point Generations Advantage is the starting point for members who want a Part D Prescription Drug covered or paid for when the member's doctor or pharmacist says that a certain prescription drug is not covered.

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 Martin's Point Generations Advantage apply in a specific situation. With this decision, we explain whether we will pay for the requested prescription drug or pay the member back for a prescription drug they have already received. If our initial decision is to deny the request, members may file an appeal.

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

Below you will find information on who can request a Coverage Determination / Exception to Martin's Point and where members/member representatives can submit their requests.

Request an expedited determination and exception

You can request "an expedited (fast) determination" or "expedited exception" if you or your doctor believes 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 your prescribing physician's supporting statement.

Request aggregate grievance, appeal, and exception data

You are entitled to obtain information (in aggregate form) about the number of grievances, appeals, and exceptions filed with Martin's Point Generations Advantage.

You may do so by filing a written request with Martin's Point Generations Advantage and sending it to:

Martin’s Point Generations Advantage, Grievance Department
PO Box 9746
Portland, ME 04104-5040

If our initial decision is to deny the request—also called an “adverse coverage determination”—the member may ask us to review that decision by requesting a redetermination. This is considered Appeal Level 1.

You have 65 days from the date on your Notice of Denial of Medicare Prescription Drug Coverage to request a redetermination.

You may also request a redetermination by phone at 1-888-296-6961 or in writing.

If submitting your request in writing, you may use the Medicare Redetermination Request Form (which includes the fax number and complete submission instructions for filing your appeal):  Medicare Redetermination Request Form [PDF]

The completed form must be sent to:

CVS Caremark-Martin’s Point Generations Advantage
Exception Department
MC109, PO Box 52000
Phoenix, AZ 85072-2000

Providing your reason for appealing

Whether you submit your redetermination online, phone or in writing, you will be asked to explain why you are appealing the coverage decision.

The mail-in Medicare Redetermination Request Form includes a limited space to explain your reason for appealing. If you need more room, you may attach additional pages or include supporting documents with your request.

If you include extra pages or attachments, please be sure your name, date of birth, and member ID number appear on each document to help ensure everything is correctly matched with your request.

You may use the explanation section—or any attached pages or uploaded documents—to explain why you disagree with the denial or why you believe coverage is needed. This may include:

• Information about how the medication affects your condition
• Why you cannot use alternative drugs on the formulary
• Any other information you feel is important to share

Clinical information may be provided by your prescriber. Your prescriber may submit medical justification, notes, treatment history, or other supporting documentation directly.

Expedited (fast) redeterminations

If you or your prescriber believe that waiting up to 7 days for a standard redetermination could seriously jeopardize your health, you may request an expedited (fast) redetermination. If your prescriber supports this request, we will make a decision within 72 hours of receiving the supporting statement.

To request an expedited redetermination by phone, call 1-888-296-6961 (TTY: 711), available 24 hours a day, 7 days a week. Instructions for requesting an expedited review are also included in the redetermination form.

If you disagree with the redetermination decision, additional levels of appeal may be available.