Form Instructions

Coverage Determinations

A coverage determination or coverage decision is HMSA’s initial decision about whether we will provide coverage for a Part D prescription drug or how much we pay.

You can ask us to make a coverage determination 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”. A “fast coverage decision” is also called an “expedited coverage determination.” When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard coverage decision means we will give you an answer within 72 hours after we receive your doctor’s statement. A fast decision means we will answer within 24 hours.

Instructions

To request a coverage determination, contact CVS Caremark. For information about the process or the status of a request, contact CVS Caremark.

Submit the completed form to MedicareCoverageDeterminations@caremark.com.

• Fill out your name, date of birth, address, phone number, and HMSA Member ID number.
  • If you are making the request on someone else’s behalf, include your name as the Requestor, your relationship to the enrollee, address, and phone number.
• List the name of the drug you are requesting a coverage decision for.
• Choose the type of coverage determination request.
• If this is a request for a "fast decision," check the box marked "I need an expedited coverage determination."
• Sign the form.
• Fill out your physician’s name and contact information. (For requests that require supporting documentation, prescribers must submit. HMSA will contact your prescriber to get required information.)

In addition to email, you can also submit your request via the contact methods below.

Call

1 (855) 479-3659 for standard and fast decisions, and tier, formulary, and utilization management exceptions and tier exceptions.

These toll-free numbers are available 24 hours a day, seven days a week.

TTY

1 (866) 236-1069

This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.

Fax

1 (855) 633-7673, or after business hours, call the toll-free numbers above. Be sure to ask for a "fast," "expedited," or "24-hour" review.

Write

Medicare Coverage Determinations and Appeals
MC 109 PO Box 52000
Phoeniz, AZ 85072-2000

Your physician or your pharmacist can also request a coverage determination on your behalf using the same form and submission methods above. Prescribers need to provide as supporting information:

• Diagnosis and Medical Information
• Rationale for Request

Medicare provides model forms for members and for providers that list the type of information needed to complete a coverage determination request. You may use these forms as a reference.

Medicare Model Coverage Determination Request Form for plan members 

Model Coverage Determination Request Form for physicians 

If you choose to use the Medicare model form instead of HMSA's form, please print out the form and complete your portion. Mail or fax it to CVS Caremark at the address or number above.