Coverage Determination and Exceptions Process 2023

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

1. You may call our Medicare Clinical Prior Authorization Department toll-free at 1-888-296-6961. Our representatives are available to take your requests 24 hours a day, 7 days a week.
2. You may fax a written request to our Medicare Clinical Prior Authorization Department at 1-855-633-7673.
3. You may send a written request via U.S. mail. Mail to CVS Caremark–Martin's Point Generations Advantage, Exception Department, MC 109, P.O. Box 52000, Phoenix, AZ 85072-2000. 

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. The member should contact Martin's Point Generations Advantage and ask us for an initial coverage decision.

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 (this is 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.

There are several types of "initial decisions":

• A member asks us to pay for a prescription drug the member has already received. This is a request for an "initial decision" about payment.
• A member asks for a Part D drug that is not on the plan's list of covered drugs (called the "formulary"). This is a request for an "initial decision" called a "formulary exception."
• A member asks for an exception to our plan's utilization management techniques. This is also a request for an "initial decision" called a "formulary exception."
• A member asks for a non-preferred part D drug at the preferred cost share level. This is a request for an "initial decision" called a "tier exception."
• 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 Martin's Point Generations Advantage apply in a specific situation.

Who may ask for an initial decision about a
Part D benefit or payment?

A Martin's Point Generations Advantage member may ask us for an initial decision. Please provide us with the doctor’s name, phone number, and fax number. The member's doctor or an appointed representative (someone else the member may name) may ask for an initial decision, also. The 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 their behalf, the member must sign and date a Medicare Appointment of Representation Form (PDF) (a statement that gives the person legal permission to act as the member's appointed representative). This form must be sent to us at the following address: Send to CVS Caremark–Martin's Point Generations Advantage, MC 109, PO Box 52000, Phoenix, AZ 85072-2000. The form may also be faxed to 1-855-633-7673.

Initial Decision vs. Making an Appeal

Whenever a Martin's Point Generations Advantage member asks for coverage under a Part D benefit, the first step is called an "initial decision" or a "coverage determination."

Coverage determinations can be faxed to 1-855-633-7673 or submitted in writing to CVS Caremark-Martin’s Point Generations Advantage, Exception Department, MC109, PO Box 52000, Phoenix, AZ 85072-2000. Members may use the Medicare's Coverage Determination Request (PDF) or call 1-888-296-6961 to request a form.

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 through the website. 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.

Expedited Determinations and Exceptions

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. For more information about expedited determinations and exceptions, call 1-866-544-7504 (TTY:711) 8 am-8 pm, seven days a week from October 1 to March 31, and Monday through Friday the rest of the year.

You are entitled to obtain an aggregate 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.

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