What If My Drug Is Not On The Formulary?
If your prescription is not listed on our formulary, ie. non-formulary, you should first contact Member Services (1-844-786-6762, 24 hours a day, 7 days a week. TTY: 711) to be sure it is not covered.
If Member Services confirms that we do not cover your drug, you have three (3) options:
How Can I Request An Exception to the Formulary?
You can ask us to make an exception to our coverage rules. Exceptions are a type of coverage determination. Providers and members can submit an exception request for drug coverage determination. These exceptions include:
Coverage Determination, Exceptions, Appeals and Grievances
Coverage Determination: A decision CareFirst makes about your benefit and coverage and the amount you will pay. If a drug is not covered or there are restrictions or limits on a drug, you may request a coverage determination.
Exceptions requests are granted when CareFirst BlueCross BlueShield Advantage determines that a requested drug is medically necessary for you. Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request.
Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe 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 a supporting statement from your doctor or other prescriber.
Appeal: A request to reconsider and change a decision or determination made about the plan services or benefits or the amount the plan will pay for a service or benefit.
Request for Redetermination of Medicare Prescription Drug Denial
To check the status of an appeal, call our customer service team at 1-844-786-6762, 24 hours a day, 7 days a week. TTY users please call 711.
How to Request a Coverage Determination
A member, prescriber, or a member's appointed representative may request a standard or expedited coverage determination. You, your prescriber or your appointed representative may request a coverage decision and/or exception any of the following ways:
Contact customer service for any requests including making an oral request related to Coverage Determination and Appeals. Our customer service team is available at 1-844-786-6762, 24 hours a day, 7 days a week (TTY users please call 711). Appeals calls are then redirected to the correct department for further action.
Online: Coverage Determination Form
CVS Caremark Coverage Determinations/Exceptions
P.O. Box 52000
Phoenix, AZ 85072-2000
You can also contact Medicare directly at 1-800-MEDICARE or file a complaint online at:
How to Request a Redetermination (Appeal)
An initial coverage determination decision can be appealed. To start your appeal, a member, prescriber, or a member's appointed representative must contact us within 60 calendar days of the date of the denial notice they received (unless the filing window is extended). You, your prescriber, or your appointed representative may ask for an expedited (fast) or standard appeal via any of the following ways:
Contact customer service for any requests related including making an oral request to Coverage Determination and Appeals. Our customer service team is available 1-844-786-6762, 24 hours a day, 7 days a week (TTY users please call 711).
Online: Redetermination Form
You can also contact Medicare directly at 1-800-MEDICARE or file a complaint online at: www.Medicare.gov/MedicareComplaintForm/home.aspx
How to Request a Grievance
A “grievance” is a complaint that does not involve a coverage determination. The grievance process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive.
Contact our customer service team at 1-844-786-6762, 24 hours a day, 7 days a week (TTY users please call 711).
P.O. Box 30016
Pittsburgh, PA 15222-0330
Appointed Representative/ Appointed of Representative (AOR)
You or your physician may request an initial determination or file a grievance or appeal. You may name a relative, friend, advocate, doctor, or anyone else as your “appointed representative” to act for you. You may already have a representative authorized under State law to act for you; however, if you want someone to act for you, you and your representative must sign and date a statement giving the person legal permission to be your appointed representative. The form is available below. Please contact your plan for more information.
Appointment of Representative Form