Coverage Determination and Exceptions Process

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. 
  4. You may request a coverage determination, exception or appeal via our website:
    For Members and Providers wishing to request prior authorization, request coverage of a non-formulary drug, or request a tiering exception.

PLEASE NOTE: Your request should include the name of the provider, e-mail address, phone number, and office contact name. This is NOT a secure email box so please DO NOT include any patient information in your request. Someone will respond to your request securely via email or phone.

Initial decisions or coverage determinations

The "initial decision" (sometimes called a coverage determination) made by Martins 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 he or she has 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 that 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 can ask us for an initial decision. Please have the doctor’s name, phone number, and fax number. The member's doctor or an appointed representative (someone else the member may name) can 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 his/her behalf, the member must sign and date a Medicare Appointment of Representation Form (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 of 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 form.

If the member is unhappy with the initial decision, the member can ask for an appeal, which is called a "redetermination." Please have the doctor’s name, phone number, and fax number. Members may send the Medicare's Redetermination Request Form 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. Please have the doctor’s name, phone number, and fax number. There are also four other levels of appeal that a member may request.

Note: Providers should use the Provider Medicare Part D Coverage Determination Request Form

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.

Have Questions? Call Us!