Pharmacy-related Grievances, Appeals & Exceptions

You may ask us to cover a drug if it is not on the formulary. You may ask us to cancel limits or restrictions on a drug. For example, certain drugs require a limit on the amount we can cover. If your drug has a limit quantity, you can ask us to waive the limit and cover more.

Grievance, Coverage Determination & Appeals Processes

This section gives a summary of the rules for making complaints in different types of situations. A complaint will be handled as a grievance, coverage determination, or an appeal, depending on the subject of the complaint.

What is a grievance?

A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with the Commonwealth Care Alliance drug benefits or one of our network pharmacies that does not relate to coverage for a prescription drug. For example, you would file a grievance if you have a problem with things such as waiting times when you fill a prescription, the way your network pharmacist or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of a network pharmacy.

What is a coverage determination?

Whenever you ask for a Part D prescription drug benefit, the first step is called requesting a coverage determination. When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exceptions requests. You have the right to ask us for an "exception" if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower co-payment. If you request an exception, your physician must provide a statement to support your request. You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination. You, your physician or your appointed representative may file a coverage determination, including an exception, by:

Telephone

Toll Free: 1-866-443-1095

Fax

1-866-511-2202

Web

Click here*

Mail

Catamaran
Med D Prior Auth and Exceptions Department
2441 Warrenville Road, Suite 610
Lisle, IL 60532

How do I file a coverage determination, including an exception?

You, your physician, or your appointed representative may file a coverage determination in the following ways:

Telephone

Toll Free: 1-866-443-1095

Fax

1-866-511-2202

Web

Click here*

Mail

Catamaran
Med D Prior Auth and Exceptions Department
2441 Warrenville Road, Suite 610
Lisle, IL 60532

Download the Model Drug Coverage Determination Form (pdf)

Download the Medicare Precription Drug Coverage Determination Form* (pdf) directly from the CMS website

Download the Request for Redetermination of Medicare Prescription Drug Denial Form (pdf)

What is an appeal?

An appeal is any of the procedures that deal with the review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.

How do I file a grievance or appeal?

You, your physician, or your appointed representative may file a grievance or appeal in the following ways:

Telephone

Toll Free: 1-866-610-2273
TTY: 711

Fax

617-426-1311

Mail

Commonwealth Care Alliance
Member Services
30 Winter Street
Boston, MA 02108

If we deny part, or all, of your request in our coverage determination, you may ask us to reconsider our decision. This is called an "appeal" or "request for redetermination." Please call us if you need help with filing your appeal. You may ask us to reconsider our coverage determination, even if only part of our decision is not what you requested. When we receive your request to reconsider the coverage determination, we give the request to people at our organization who were not involved in making the coverage determination. This helps ensure that we will give your request a fresh look. You may also mail your request for redetermination to:

Commonwealth Care Alliance
Member Services
30 Winter Street
Boston, MA 02108

Or Fax

617-426-1311

You may also utilize your MassHealth Appeal Rights

You may request a fair hearing from MassHealth no later than 30 calendar days from the date you received your written denial notice from Commonwealth Care Alliance Senior Care Options. The request must contain:

your name
your address and phone number
your MassHealth ID number or Social Security number
your reason for appeal
if you would like your hearing to be scheduled as soon as possible
if you need an interpreter to be provided, and
if you would like to name a representative to appeal on your behalf

The request must be signed and sent to:

Executive Office of Health and Human Services
Board of Hearings
100 Hancock Street, 6th Floor
Quincy, MA 02171

Or faxed to (617) 847-1204

Please keep one copy of the fair hearing request for your information.

If you do not agree with the fair hearing decision, you will have further appeal rights under MassHealth. You will be notified of those appeal rights if this happens.

For more information about your appeal rights, please call our Member Services team toll-free at 1-866-610-2273 (TTY 711) or see your Evidence of Coverage.

Where do I find additional information about grievances, coverage determinations, and appeals?

Please see your Evidence of Coverage for more information on our grievance, coverage determination, and appeals process. Refer to Chapter 8: What to do if you have a problem or complaint (coverage decisions, appeals, complaints).

If you have any questions about any of these processes, or if you want to inquire about the status of a grievance, coverage determination or appeal request, you, your physician or your appointed representative may contact us at:

Toll Free: 1-866-610-2273
TTY: 711

How do I appoint a representative?

If you need someone to file a grievance, coverage determination or appeal on your behalf, you can name a relative, friend, advocate, doctor, or anyone else as your appointed representative. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative.

If you are requesting a coverage determination through an appointed representative, you should download form CMS-1696*, complete it, and mail it to:

Commonwealth Care Alliance
Member Services
30 Winter Street
Boston, MA 02108

Or Fax

617-426-1311

If you have any questions about naming your appointed representative, you can call us at:

Toll Free: 1-866-610-2273
TTY: 711

To download these documents, you must have Adobe Acrobat Reader installed. If you do not have Adobe Acrobat Reader installed on your computer, click here* to download and install a free version of Adobe Acrobat Reader.

To search an Adobe PDF file using Adobe Acrobat Reader, click on the "Search" icon (the button with the binoculars) on the Acrobat file toolbar or choose "Edit > Search" from the Acrobat menu. In the "Search PDF" window that opens, type in the word or phrase you are looking for and click on "Search".

The cursor will jump to the first place in the document that word or phrase appears and a search results box will appear listing all the occurrences of that word or phrase. You can jump to any particular instance of the word or phrase by clicking on that item in the results box. You can also use the "Edit > Search Results > Next Result" or "Edit > Search Results > Previous Result" in the Acrobat menu to navigate forwards or backwards to the next item.

*When you click this link, you will leave Commonwealth Care Alliance's web site

Last Updated 1/1/13