Located in Chapter 7, Section 7 of the EOC: Making Complaints

To submit a grievance verbally, contact Customer Service at:
918-594-5202 or 1-800-333-3275, TTY/TDD: 1-800-722-0353, Monday through Friday from 8am to 8pm, CST.

To submit a formal grievance in writing, send to:
CommunityCare Prescription Drug Plan
Attn: Grievance and Appeals Department
P.O. Box 340
Tulsa, OK 74101-0340

Fax Number: 918-879-4048

In person: 4720 S. Harvard, Suite 101, Tulsa, OK 74135 (Senior Center)

Medicare website:
You can submit a complaint about CommunityCare Prescription Drug Plan directly to Medicare. To submit an online complaint to Medicare go to Medicare Complaint Form.

Located in Chapter 7, Section 5 of the EOC: Your Part D prescription drugs: How to ask for a coverage decision or make an appeal

To request a coverage determination verbally, contact CVS Caremark Part D Exceptions Department at 1-844-232-2313, TTY/TDD: 711, 24 hours a day, 7 days a week

To submit a request in writing, send to:
CVS Caremark Part D Exceptions Department
P.O. Box 52000 MC 109
Phoenix, AZ 85072-2000

Fax Number: 1-855-633-7673

Enrollees & Providers:

• Coverage Determination Request Form - updated 9/3/2020
• Online Coverage Determination Form

Located in Chapter 7, Section 5 of the EOC: Your Part D prescription drugs: How to ask for a coverage decision or make an appeal

Requests for Appeal Level 1 redeterminations must be in writing unless the request is for a fast or expedited decision.

Members must file their appeal within 60 calendar days from the date included on the notice of the coverage decision. Exceptions may be granted if you have a good reason for missing the deadline.

To submit a fast appeal verbally, contact Customer Service at: 918-594-5202 or 1-800-333-3275, TTY/TDD: 1-800-722-0353, Monday through Friday from 8am to 8pm, CST.

To submit a standard appeal in writing, send to:

CommunityCare Prescription Drug Plan
Attn: Grievance and Appeals Department
P.O. Box 340
Tulsa, OK 74101-0340

Fax Number: 918-879-4048

In person: 4720 S. Harvard, Suite 101, Tulsa, OK 74135 (Senior Center)

A standardized Redetermination Request Form is available. However, you may submit your request in any format.

• Part D Appeal Request Form - updated 9/26/2019
• Initiate a Part D appeal

Located in Chapter 3, Section 4 of the EOC: There are restrictions on coverage for some drugs

For prescribing physicians to submit a prior authorization request verbally, contact CVS Caremark Part D Exceptions Department at 1-844-232-2313, TTY/TDD: 711, 24 hours a day, 7 days a week.

To submit a prior authorization in writing, send to:
CVS Caremark Part D Exceptions Department
P.O. Box 52000 MC 109
Phoenix, AZ 85072-2000

Fax Number: 1-855-633-7673

Physicians may use the attached Prescription Authorization Form to request prior authorization. Click on the link to print a copy of this form to take to your physician.

• Coverage Determination Request Form - updated 9/3/2020

Chapter 7, Section 5 of the EOC: Your Part D prescription drugs: How to ask for a coverage decision or make an appeal

There is no standardized form for a prescribing physician to use to present supporting statements or documents.

For a prescribing physician to submit a supporting statement verbally, contact CVS Caremark Part D Exceptions Department at 1-844-232-2313, TTY/TDD: 711, 24 hours a day, 7 days a week

To submit supporting documents in writing, send to:
CVS Caremark Part D Exceptions Department
P.O. Box 52000 MC 109
Phoenix, AZ 85072-2000

Fax Numbers: 1-855-633-7673

Questions about grievances, coverage decisions and appeals can be answered by our Customer Service Department.

Contact Customer Service at: 918-594-5202 or 1-800-333-3275, TTY/TDD: 1-800-722-0353, Monday through Friday from 8am to 8pm, CST.

For Coverage Decisions about Part D Prescription Drugs: call 1-844-232-2313, TTY/TDD: 711, available 24 hours a day, 7 days a week.

For Part D Appeal status: contact Customer Service at: 918-594-5202 or 1-800-333-3275, TTY/TDD: 1-800-722-0353, Monday through Friday from 8am to 8pm, CST.

For Part D Grievance status: contact Customer Service at 918-594-5202 or 1-800-333-3275, TTY/TDD: 1-800-722-0353, Monday through Friday from 8am to 8pm, CST.

Located in Chapter 7, Section 4 of the EOC: A guide to the basics of coverage decisions and appeals

If you have someone appealing our decision for you other than your doctor, your appeal must include an Appointment of Representative form authorizing this person to represent you. A completed standardized form is required in order to appoint a representative. To print this form, click on the following link:

• Appointment of Representative Form

This form is also available on Medicare's website at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf.

Instructions for completing the Appointment of Representative form:

To submit a completed Appointment of Representation Form, send to:

For information on how to obtain an aggregate number of grievances and appeals, contact Customer Service at: 918-594-5202 or 1-800-333-3275, TTY/TDD: 1-800-722-0353, Monday through Friday from 8am to 8pm, CST.

For additional detail on coverage decisions, complaints and appeals, the following sections in Chapter 7 are located in your 2021 Evidence of Coverage:

• Section 4 - A guide to the basics of coverage decisions and appeals.
• Section 5 - Your Part D prescription drugs: How to ask for a coverage decision or make an appeal.
• Section 6 - Taking your appeal to Level 3 and beyond.
• Section 7 - How to make a complaint about quality of care, waiting times, customer service, or other concerns.