is the first decision we make about an exception to cover a drug you've requested if we don’t cover it already.
is how you ask the plan to review a denied coverage determination.
is a complaint about anything other than a decision about drug coverage. You can file a grievance if you're unhappy with Clover, one of our pharmacies, or prescription drug service.
As a plan member, federal law guarantees your right to take these steps if you're in any way dissatisfied with a part of your coverage.
If you file a complaint, we must process it fairly. You can't be dis-enrolled or penalized in any way for making a complaint.
You can have an authorized representative—like a trusted friend or family member—make some of these requests for you.
To do so, include this authorized representative form with your appeal, grievance, or prior authorization.
It’s a way of finding out whether we’ll cover the drug treatment you want and make an exception to our normal rules. Examples of why you may ask for an exception include: formulary coverage, prior authorizations, quantity limits, and copay tier level.
Before getting started, it’s important to know that in order to process a coverage determination request, you’ll need a statement from your doctor. This statement must indicate that the requested drug is medically necessary for treating your condition because no other covered drug would be as effective, or alternate medications would have adverse effects on you. Note: If the exception involves a pre-authorization, quantity limit, or another limit we've placed on that drug, the doctor’s statement must also indicate that the pre-authorization or limit wouldn't be appropriate given your condition, or would have adverse effects on you.
This form can be mailed to:
CVS Caremark
Attention – Prior Authorization – Part D
P.O. Box 52000, MC109
Phoenix, AZ 85072-2000
Then to request a coverage determination, you can:
CVS Caremark
Attention – Prior Authorization – Part D
P.O. Box 52000, MC109
Phoenix, AZ 85072-2000
Once the physician’s statement is submitted, we'll notify you of our decision within 24 hours for expedited requests. Your request will be expedited if we determine—or your doctor informs us—that your life, health, or ability to regain maximum function may be seriously jeopardized by awaiting a standard request. If the exception was a standard request, we'll make a decision within 72 hours.
You can also check your coverage determination status online. Sign in to the Clover Member Portal and then click on the Prescription Web Portal by Caremark.
You must request an appeal within 65 calendar days from the date of our first decision. We accept standard and expedited requests by phone and in writing. The best way to complete this process is to ask your prescribing doctor to contact us.
To submit an appeal, you can:
If your appeal request is denied, you have the right to a Level 2 Appeal (Reconsideration) with an Independent Review Organization within 65 calendar days from the date of Clover Health’s appeal decision.
To initiate a Reconsideration, please reach out to C2C Innovative Solutions, Inc. via:
To file a grievance, you or your representative may:
CVS Caremark Medicare Part D - Grievances
P.O. Box 30016
Pittsburgh, PA 15222-0330
We strive to provide excellent service and medications needed to stay healthy. As a member, you have the right to complain if you're not satisfied with your coverage. Medicare has rules for how you should file complaints and how Clover Health must handle them. We will process your complaint fairly, and you won't be penalized for making one. Your complaint will be handled as a coverage determination, appeal, or grievance, depending on what it's about. To find out the total number of complaints, appeals, and exceptions filed with Clover Health, contact us at:
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The form for submitting a provider service request is hosted on a non-Clover website. However, the requests are read and responded to by Clover. If you do not wish to submit a service request via a non-Clover website, please click Cancel.
Traditional Medicare covers hospitals (Part A) and doctors (Part B), and you pay standard rates for services. You can go to any doctor, hospital or other provider that accepts Medicare patients anywhere in the country.
You can add drug coverage (Part D) by enrolling in a private "stand-alone" drug plan for an additional premium. You can buy separate Medigap insurance to cover some or most of the out-of-pocket costs of hospitals (Part A) and doctors (Part B).
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