Part D Prescription Plan Rights
Coverage Determinations (Decisions)
A coverage determination is a decision we make about your benefits and coverage or about what we will pay for your drugs. If you feel you may qualify for an exception because of your unique medical needs, you or your physician should contact us and ask for a coverage determination.
Please note: If your pharmacy tells you that your prescription cannot be filled as written, you will get a written notice explaining how to contact us to ask for a coverage decision.
Here are examples of coverage decisions you may ask us to make about your Part D drugs:
- You may ask us to make an exception, including:
- Asking us to cover a Part D drug that is not on the plan’s formulary.
- Asking us to waive restriction on the plan’s coverage for a drug (such as limits on the amount of the drug you can get).
- Asking to pay a lower cost-sharing amount for a covered non-preferred drug.
- You may ask us whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on the plan’s formulary but we require you to get approval from us before we will cover it for you.)
- You may ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment.
If you disagree with a coverage decision we have made, you can appeal our decision.
Requesting a Coverage Determination
CareSource delegates responsibility for making coverage determinations to a Pharmacy Benefits Manager (PBM), Express Scripts®. You, your appointed representative or your prescribing physician may request a coverage determination.
You must ask us to make a coverage decision about the drug(s) or payment you need. If your health requires a quick response, you must ask us to make a “fast coverage decision.”
How to Request a Coverage Determination
To request a decision, you have the following options:
- Online: Complete the Coverage Determination Request Form online.
- Call Member Services: The number is found at the bottom of this page.
- Fax or Mail: Download the
Coverage Determination Request Form and fax or mail it to us.
- Fax: 1-877-251-5896
- Mail: Express Scripts, ATTN: Medicare Review
P.O. BOX 66577
St Louis, MO 63166-6577
Providers can complete the Coverage Determination Request Form to provide supporting statements for an exception request.
If you are unsatisfied with the outcome of a coverage determination request, you can ask for an appeal. When you make an appeal, CareSource or the CareSource PBM for Part D drugs will review your unfavorable coverage determination or organization determination.
The first level of appeal for a Part D drug is called a redetermination. You may file for a Part D redetermination if you want CareSource to reconsider a decision regarding payment or benefits to which you believe you are entitled. There are five levels of appeals. Details of all levels can be found in the Evidence of Coverage (Chapter 9, sections 8 and 9). To locate this document and more, visit our Plan Documents page.
Requesting an Appeal
You, your appointed representative or your prescribing physician may file for an appeal of a coverage determination.
Appeals must be filed within 60 calendar days of the date included on the notice of the CareSource coverage determination. More time may be granted depending on circumstances.
How to Request an Appeal
To file a standard redetermination (appeal) request, you have the following options:
- Online: Complete the Coverage Redetermination Request Form online.
- Call Member Services: The phone number is found at the bottom of this page.
- Fax or Mail: Download the
Coverage Redetermination Request Form and fax or mail it to us.
- Fax: 1-877-852-4070
- Mail: Express Scripts, c/o Medicare Clinical Appeals P.O. Box 66588, St. Louis, MO 63166-6588
If your first appeal is denied or if you disagree with any part of our appeal (redetermination or reconsideration) decision, you can request further appeal levels. Complete details on all appeal levels can be found in the Evidence of Coverage.
Appointing a Representative
An appointed representative is a relative, friend, advocate, doctor or other person authorized to act on your behalf in filing a grievance, coverage determination or appeal.
Those not authorized under state law to act for you will need to sign an Appointment of Representative Form and mail it to: Express Scripts, c/o Medicare Clinical Appeals, P.O. Box 66588, St. Louis, MO 63166-6588
For questions regarding the process or status of a coverage determination, organization determination, redetermination or reconsideration request, you or your appointed representative should call CareSource Member Services. The phone number is found at the bottom of this page.
A grievance is any dispute (other than one involving a coverage determination or an organization determination) that expresses dissatisfaction with the operations, activities or behavior of CareSource or one of our providers. Complete details on grievances can be found in the Evidence of Coverage (Chapter 9). To locate this document and more, visit our Plan Documents page.
Examples of grievances:
- Unresolved issues with Member Services
- Problems with one of our network providers
- Problems with waiting times at your physician’s office
- Suspicion of fraud or abuse
- Marketing or sales activities you feel are inappropriate
How to File a Grievance
- Phone: If you would like to file a verbal grievance, you can call Member Services.
- Mail: If you would like to file a grievance in writing, please send your grievance to CareSource Dual Advantage Complaints, P.O. Box 1947, Dayton OH, 45401-1947.
When your complaint is about quality of care, you can make your complaint to the Quality Improvement Organization (QIO). To find the name, address, and phone number of the QIO for your state, look in your Evidence of Coverage (Chapter 2, section 4). This document and others are available on our Plan Documents page.
You can also submit feedback directly to Medicare by using the Medicare Complaint Form. You can also call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users can call 1-877-486-2048.
Grievances, Appeals, and Exceptions Data
CareSource tracks and maintains records about the receipt and handling of grievances, appeals and exceptions. We will also disclose grievances, appeals and exceptions data to you upon request. CareSource can also provide an aggregate number of grievances, appeals and exceptions filed with our plans. To obtain this data, please call Member Services.
This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits and/or copayments/coinsurance may change on January 1 of each year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
CareSource Member Services at 1-833-230-2020 (TTY: 711). We are open 8 a.m. to 8 p.m. Monday through Friday, and from October 1 through March 31 we are open the same hours, seven days a week.