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.

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 04104-9895

If our initial decision is to deny the request, sometimes called an "adverse coverage determination", the member can appeal the decision by requesting a "redetermination." This is considered Appeal Level 1.

If we fail to make a timely "initial decision" on the request, it will be automatically forwarded to an independent review entity (a contracted group of qualified practitioners who are not employed by Martin's Point Health Care) for review.

If the member is unhappy with the initial decision, the member can ask for an appeal, which is called a "redetermination." An appeal can be requested by phone, in writing, and online. Please provide us with the doctor’s name, phone number, and fax number.

Members may also send the Medicare's Redetermination Request Form [PDF] to:

CVS Caremark–Martin's Point Generations Advantage
Medical Appeals Department
MC 109, PO Box 52000
Phoenix, AZ 85072-2000

The form may also be faxed to 1-855-633-7673. There are also four other levels of appeal that a member may request.