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Coverage Determination and Payment Request (Prescription Part D)

It’s possible there could be a prescription drug you are currently taking, or one that you and your provider think you should be taking, that is not on our drug list or is on our drug list with restrictions. There are things you, your representative*, or your provider can do if your drug is not covered in the way that you would like it to be covered.

If there is a restriction on the drug, you, your representative*, or your provider can ask for a coverage determination.

Contact CVS Caremark to submit a Coverage Determination:

Online 

www.link.com TBD
Complete the information at the link above 

Phone

1-888-970-0914
You can request a coverage determination


Mail

Attn: CVS Caremark Prior Authorization

P.O. Box 52000, MC109
Phoenix, AZ 85072-2000

Download and complete our Coverage Determination Form and mail to the address above

Fax

1-855-633-7376
Download and complete our Coverage Determination Form and fax to the number above


*Please note, that in order for your appointed representative to initiate a coverage decision for you, a valid and up-to-date Appointment of Representative (AOR) Form must be on file.

To complete a CVS AOR form or check the status of an CVS AOR form previously submitted, please contact CVS Caremark. 


If you disagree with a decision made on a previous coverage decision, you, your representative, or your provider can ask for a Redetermination appeal.

Contact KelseyCare Advantage to submit a Redetermination appeal:

Online

Part D Redetermination (Appeal) 

Phone

1-866-8343 (TTY 711)

Mail

KelseyCare Advantage
Attn: Appeals & Grievances Department
P.O. Box 841569
Pearland, TX 77584-9832

Download and complete our Coverage Redetermination Appeal Form and mail to the address above


Fax

713-442-9536

Download and complete our Coverage Redetermination Appeal Form and fax to the number above


*Please note, that in order for your appointed representative to initiate a coverage decision for you, a valid and up-to-date Appointment of Representative (AOR) Form must be on file.

To complete a KelseyCare Advantage AOR form or check the status of a KelseyCare Advantage AOR form previously submitted, please contact KelseyCare Advantage.

Payment Request for Part D Drugs

Below is a brief description of some of the situations you may submit a paper claim for reimbursement for your Part D drug expenses. For a full description and a complete listing of all situations, refer to the Evidence of Coverage, Chapter 7. Some of the situations you may submit a paper claim include:

  • When you pay the full cost for a prescription because you don’t have your plan membership card with you.
  • When you pay the full cost for a prescription drug that is not on the plan’s List of Covered Drugs (Formulary); or the drug has a requirement or restriction that you didn’t know about or don’t think should apply to you.
  • When you use an out-of-network pharmacy to get a prescription filled under one of the following three circumstances:
  • Non-routine situations when a network pharmacy is not available
  • If you are traveling within the United States and territories and you become ill, run out or lose your drugs
  • Prescriptions that are written as part of a medical emergency or urgent care visit.

Please note, you must submit your claim to us within 36 months of the date you received the drug.

When you send us your request for reimbursement, include a copy of your bill and documentation of any payment you have made. It’s a good idea to make a copy of your bill and receipts for your records. Make sure you are giving us all the information we need to make a decision. You don’t have to use our form, but it’s helpful for our plan to process the information faster. You can download a copy of the Direct Member Reimbursement Form or call Member Services and request it.

KelseyCare Advantage Direct Member Reimbursement Form (PENDING)

Mail your request for payment and the Direct Member Reimbursement Form together with any bills or receipts to this address:

CVS Caremark Part D Services
P.O. Box 52066
Phoenix, AZ 85072-2066

You can also contact CVS Caremark at 1-888-970-0914 (TTY: 711)

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