Part D Prescription Plan Rights

Coverage Determinations (Decisions)

A decision we make about the payment for a Part D drug or an exception to our formulary. If you believe you are entitled to payment or benefits on a certain drug, you can request a coverage determination.

If your prescription requires approval (prior authorization) prior to being filled, 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:

  • 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.

Who Can Ask for a Coverage Determination?

  • You
  • Your appointed representative
  • Your provider

Our Pharmacy Benefits Manager, Express Scripts® is in charge of making our coverage decisions.

How to Ask for a Coverage Determination

You have these options:

Providers can complete the Navigate Coverage Redetermination Request Form  to give supporting statements for the request.


An appeal is a request for CareSource to review the decision they made to provider or pay for a drug.

There are five levels of appeals. Details of these levels can be found in Chapter 9 in sections 8 and 9 of the Evidence of Coverage on our Plan Documents page.

Who Can Ask for an Appeal?

  • You
  • Your appointed representative
  • Your provider

Asking for an Appeal

You have 60 days from the date on your organization decision to file an appeal. More time may be given based on your situation. If you file an appeal after those 60 days, you need to include a written statement of Good Cause to ask that your appeal be reviewed past the limit.

How to Ask for an Appeal

You have these options:

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 decision, you can ask for further appeal levels.


This is an official complaint. This is the first step of the process if you are unhappy with your benefits and services or if you do not agree with a decision that was made regarding your medical care. See more about grievances in Chapter 9, section 10 in your Evidence of Coverage on our Plan Documents page.

How to File a Grievance

  • Phone: Call Member Services.
  • Mail: Send your grievance to CareSource Dual Advantage Complaints, P.O. Box 1947, Dayton OH, 45401-1947.

Is your complaint about quality of care? You can make your complaint to the Quality Improvement Organization (QIO). Find the name, address and phone number of the QIO for your state in your Evidence of Coverage in Chapter 2, section 4 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 keeps records about the receipt and handling of grievances, appeals, and exceptions. We will also share grievances, appeals and exceptions data to you if you ask. We can also give you the total number of grievances, appeals and exceptions filed with our plans. To get this data, call Member Services.

Request Status

Call Member Services for an update on the process or status of a decision.

Appointing a Representative

You can have a relative, friend, advocate, provider or other person who can act on your behalf in filing a grievance, coverage determination, organization determination or appeal. We call these people appointed representatives.

Those not authorized under state law to act for you will need to sign an Appointment of Representative Form. Complete it by

CareSource Member Services at 1-833-230-2020 (TTY: 1-833-711-4711 or 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.