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Prescription Drug Coverage: Your Rights

Part D Coverage Determinations, Appeals, and Grievances

At Devoted, we always aim to offer our members excellent service and the medications they need to stay healthy. But if you ever have problems with any part of your Devoted Health drug coverage, federal laws give you the right to:

  • Ask for a coverage determination to find out if we’ll cover a specific drug treatment
  • Make an appeal about a coverage determination we made
  • File a complaint (grievance) related to your drug coverage

You can’t be disenrolled or get a penalty for doing any of these things — these are your rights as a member of our plan. Medicare has rules about how you can take these actions — and how we have to handle them when you do. That’s what the rest of this section is about.

Know that we’ll take your request seriously and deal with it fairly — not just because it’s the law (which it is), but because it’s the right thing to do. If you’d like to know the total number of coverage determinations, grievances, and appeals that have been filed with us, call 1-800-DEVOTED (1-800-336-6833), TTY 711.

You can have an authorized representative — like a trusted friend or family member — make some of these requests for you. Use this form to choose an authorized representative.

Ask for a Coverage Determination

Devoted covers thousands of drugs. But it’s possible you may not be able to get the exact drug or dosage you expected. 

If that happens, you can ask for a coverage determination. It’s a way of finding out whether we’ll cover the drug treatment you want and make an exception to our normal rules. 

Examples of why you might ask for a coverage determination:

  • We don’t normally cover the drug you want
  • You think your copay for a drug is too high
  • We set a limit on how much of a drug you can get and you don’t agree with it
  • We want you try a different drug first before you can get the medication you asked for — and you’d rather not

How do I ask for a coverage determination?
You have a few different ways. And no matter which one you choose, you’ll need a statement from your doctor that supports your request. It needs to say that:

  • You need this drug to treat your condition (it’s medically necessary)
  • Similar drugs that we cover wouldn’t work as well or might harm you
  • Our normal rules — like prior authorization, step therapy, or other limits — shouldn’t apply in your case because it could cause you harm (you only need this if you're asking that we don’t apply these normal rules to you)

Once you have that statement, you can ask for a coverage determination:

By phone. You, your doctor, or your representative can call us at 1-800-DEVOTED (1-800-338-6833), TTY 711

Online. You, your doctor, or your representative can fill out our online coverage determination form.

Fill Out Coverage Determination Form

By fax or mail. You, your doctor, or a representative can fill out a form called Request a Medicare Prescription Drug Coverage Determination. 

View Coverage Determination Form (Link coming soon.)

You can fax the completed form to our pharmacy partner, CVS Caremark, at 1-855-633-7673.

Or mail it to:
CVS Caremark Coverage Determinations/Exceptions
P.O. Box 52000, MC109
Phoenix, AZ  85072-2000

What happens next?
Our team will make a careful decision based on your medical needs and Medicare’s guidelines. Then we’ll send you a letter explaining what we decided.

Normally, we’ll make a decision within 72 hours of when we get the request. But if your doctor thinks waiting that long could harm your health, you can ask for an faster (expedited) response. In that case, we’ll let you know our decision within 24 hours.

Make an Appeal

What happens if you don't agree with our coverage determination?

You have the right to file an appeal (request for redetermination). It’s a way of asking us to rethink our coverage determination.

You can ask for one:

By phone. You, your representative, or your doctor can call us at 1-800-DEVOTED (1-800-338-6833), TTY 711.

Online. You, your doctor, or your representative can fill out our online appeals (coverage redetermination) form.

Fill Out Appeals Form

By fax or mail. You, your doctor, or a representative can fill out a paper form called Request for Redetermination of Medicare Prescription Drug Denial.

View Redetermination Form (Link coming soon.)

You can fax the completed form to our pharmacy partner, CVS Caremark, at 1-855-633-7673.

Or mail it to:
CVS Caremark Coverage Determinations/Exceptions
P.O. Box 52000, MC109
Phoenix, AZ  85072-2000

What’s the deadline for filing appeals?
You need to file your appeal within 60 days of the date on the coverage determination letter we sent.

What if I disagree with the answer to my appeal?
You can choose to make a second appeal (also called a reconsideration). This time, Devoted won’t make the decision. Instead, an outside group of experts will review your case to see if we made the right call.

This organization is called an Independent Review Entity (IRE) — it works directly for Medicare, not Devoted Health.

To file a second appeal, you, your representative, or your doctor will need to fill a form called Request for Reconsideration of Medicare Prescription Drug Denial.

View Reconsideration Form (Link coming soon.)

You can fax the completed form to our pharmacy partner, CVS Caremark, at 1-855-633-7673.

Or mail it to:
CVS Caremark Coverage Determinations/Exceptions
P.O. Box 52000, MC109
Phoenix, AZ  85072-2000

File a Complaint (Grievance) 

Complaints are different from coverage determinations and appeals. They’re not about problems you’re having getting a specific medication. Instead, complaints are about any other issues related to Devoted Health’s prescription drug service. 

Examples of why you might file a complaint:

  • You didn’t get the care you expected from a pharmacy
  • You had to wait a long time to get a prescription filled
  • Your mail order prescriptions aren’t arriving on time

How do I file a complaint?
The first step is to call us at 1-800-DEVOTED (1-800-338-6833), TTY 711. Hopefully, we can get the problem fixed right away on the phone.

You can also fax a written complaint to our pharmacy partner, CVS Caremark at 1-866-217-3353.

Or mail it to:
CVS Caremark Medicare Part D Grievance Department
P.O. Box 30016
Pittsburgh, PA 15222-0330

Once we receive your complaint, we’ll respond to you within 30 days.