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  • For Members & Patients

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. 


Table of Contents
  1. Coverage Requirements & Limits
  2. Coverage Determination Process & Initial Decisions
  3. Requesting a Coverage Determination or Exception
  4. Expedited Determination Requests
  5. Appealing a Coverage Decision

 

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Coverage Requirements and Limits

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

Quantity Limits

For certain drugs, Martin's Point Generations Advantage limits the amount of the drug that the plan will cover. For example, the plan covers 60 capsules per 30-day prescription for celecoxib 200mg.

Prior Authorizations

Martin's Point Generations Advantage requires you to get prior authorization for certain drugs. This means that you will need to get approval from Martin's Point Generations Advantage before you fill your prescriptions. If you don't get approval, Martin's Point Generations Advantage may not cover the drug.

2024 Prior Authorization Criteria | Prime, Select, and Access Plans (PDF)

2024 Prior Authorization Criteria | Value Plus Plan (PDF)

Medication Step Therapy

In some cases, Martin's Point Generations Advantage requires you to try safer or more effective drugs before the plan covers another drug.

For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. This requirement to try a different drug first is called "Step Therapy." 

You can find out if your drug has any additional requirements or limits by looking in the 2024 online formulary. 

2024 Step Therapy Criteria | Prime, Select, and Access Plans (PDF)  

2024 Step Therapy Criteria | Value Plus Plan (PDF) 

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.

TYPES OF INITIAL DECISIONS INCLUDE:
  • 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.

Requesting an Initial Coverage Determination or Exception

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.

 

medicare icon

MEMBER REQUEST
SUBMISSIONS

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

Download and complete the Medicare's Coverage Determination Request form and provide us with the prescriber’s name, phone number, and fax number.

  

Members can also call 1-888-296-6961 to request a form, or submit a request online.  

The completed form must be sent to:

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

Request forms can also be faxed to 1-855-633-7673.

people group icon

REPRESENTATIVE REQUEST
SUBMISSIONS

Generations Advantage members can also opt to appoint a representative who may request an initial coverage determination or exception.  

If a member wants someone to act on their behalf, the member must sign and date a  Medicare Appointment of Representation form.

  

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. 

This form must be sent to the following address:

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

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 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

 

Filing a Redetermination or Appeal

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.

 

Have questions? We're here to help.

If you have questions about your plan, you can talk to a Member Service Representative by calling 1-866-544-7504.

Our representatives are available from 8am-8pm, Monday to Friday.