The resource information linked to the CommunityCare Options formulary web page pertaining to grievances, coverage decisions (including exceptions), and appeals processes are taken directly from the 2023 Evidence of Coverage (EOC) document Members receive at the beginning of each year. To print a copy of the current plan year Evidence of Coverage (EOC) for Deluxe or Premier, please click the link.
Click on a topic below for more information.
Located in Chapter 9, Section 10 of the 2023 Evidence of Coverage: 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 8:00 am to 8:00 pm
To submit a formal grievance in writing, send to:
CommunityCare Options
Attn: Grievance and Appeals Department
P.O. Box 340
Tulsa, OK 74101-0340
Fax Number: 918-879-4048
Located in Chapter 9, Section 5 of the 2023 Evidence of Coverage: Your Medical Care: How to ask for a Coverage Decision or make an Appeal.
To request a coverage decision verbally, contact Customer Service at
1-800-333-3275 or
918-594-5202 (local);
TTY/TDD: 1-800-722-0353,
Monday through Friday from 8:00 am to 8:00 pm.
To submit a request in writing, send to:
CommunityCare Options
Attn: Customer Service
P.O. Box 340
Tulsa, OK 74101-0340
Fax Number: 918-594-5250
Located in Chapter 9, Section 6 of the 2023 Evidence of Coverage: "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 1-844-232-2314, 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:
Located in Chapter 9, Section 5 of the 2023 Evidence of Coverage: Your medical care: How to ask for a coverage decision or make an appeal.
If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. A standardized appeal request form is available. However, you may submit your request in any format. To print this form, click on the following link:
To submit an appeal request in writing, send to:
CommunityCare Options
Attn: Grievance and Appeals Department
P.O. Box 340
Tulsa, OK 74101-0340
Requests for appeals must be in writing unless the request is for a fast or expedited decision.
Members must file their appeal request 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
1-800-333-3275 or
918-594-5202 (local);
TTY/TDD: 1-800-722-0353.
Monday through Friday from 8:00 am to 8:00 pm.
Fax Number: 918-879-4048
When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who make the unfavorable decision. When we complete the appeal review, we will give you our decision in writing.
Located in Chapter 9, Section 6 of the 2023 Evidence of Coverage: 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 8:00 am to 8:00 pm.
To submit a standard appeal in writing, send to:
CommunityCare Options
Attn: Grievance and Appeals Department
P.O. Box 340
Tulsa, OK 74101-0340
Fax Number: 918-879-4048
A standardized Redetermination Request Form is available. However, you may submit your request in any format.
Located in Chapter 5, Section 4 of the 2023 Evidence of Coverage: 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 1-844-232-2314, 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.
Chapter 9, Section 6 of the 2023 Evidence of Coverage: 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, however the prescribing physician may submit the coverage determination form. Pages 3 through 5 of the form allows for the physician to submit supporting information for an exception request or prior authorization.
For a prescribing physician to submit a supporting statement verbally, contact CVS Caremark Part D Exceptions Department at 1-844-232-2314, TTY/TDD: 711, 711
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 8:00 am to 8:00 pm
OR
TTY/TDD: 711,
available 24 hours a day, 7 days a week
For Coverage Decisions about Part D Prescription Drugs:
call 1-844-232-2314
TTY/TDD: 711,
available 24 hours a day, 7 days a week.
For Coverage Decisions about Medical Care: contact Customer Service at
918-594-5202 or
1-800-333-3275
TTY/TDD: 1-800-722-0353,
Monday through Friday from 8:00 am to 8:00 pm
OR
TTY/TDD: 711,
available 24 hours a day, 7 days a week
For Part D or Part C Appeal status: contact Customer Service at
918-594-5202 or
1-800-333-3275
TTY/TDD: 1-800-722-0353,
Monday through Friday from 8:00 am to 8:00 pm
OR
TTY/TDD: 711,
available 24 hours a day, 7 days a week
For Part D or Part C Grievance status: contact Customer Service at
918-594-5202 or
1-800-333-3275
TTY/TDD: 1-800-722-0353,
Monday through Friday from 8:00 am to 8:00 pm
OR
TTY/TDD: 711,
available 24 hours a day, 7 days a week
Located in Chapter 9, Section 4 of the 2023 Evidence of Coverage: A guide to the basics of coverage decisions and appeals
If you have someone requesting a coverage determination, an exception, or an appeal for you other than your doctor,
your request 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:
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:
| Section 1: | The member (beneficiary) completes the requested information in Section I including the name of the individual they appoint as their representative. The beneficiary's signature is required. |
|---|---|
| Section 2: | This section is completed by the individual the beneficiary has named as their representative. The representative's signature is required. |
| Section 3 and Section 4: | These sections may not apply. See page 2 of the form for further information. |
To submit a completed Appointment of Representation Form, send to:
| For all Appeals |
|---|
|
CommunityCare Options Attn: Grievance and Appeals Department P.O. Box 340 Tulsa, OK 74101-0340 Fax Number: 918-879-4048 |
| For Part C Coverage Determinations and Exceptions |
|
CommunityCare Options Attn: Customer Service P.O. Box 340 Tulsa, OK 74101-0340 Fax Number: 918-594-5250 |
| For Part D Coverage Determinations and Exceptions |
CVS Caremark Part D Exceptions Department P.O. Box 52000 MC 109 Phoenix, AZ 85072-2000 Fax Number: 1-855-633-7673 |
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 8:00 am to 8:00 pm
OR
TTY/TDD: 711,
available 24 hours a day, 7 days a week
For additional detail on coverage decisions, complaints and appeals, the following sections in Chapter 9 are located in your 2023 Evidence of Coverage for Deluxe or Premier: