Located in Chapter 9, Section 10 of the 2024 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 2024 Evidence of Coverage: Your medical care: How to ask for a coverage decision or make an appeal of a coverage decision.

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 2024 Evidence of Coverage: "Your Part D prescription drugs: How to ask for a coverage decision or make an appeal of a coverage decision"

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
• Initiate a Part D decision online - coming soon

Located in Chapter 9, Section 5 of the 2024 Evidence of Coverage: Your medical care: How to ask for a coverage decision or make an appeal of a coverage decision.

If we make a coverage decision, whether before or after a benefit is received, and you are not satisfied, 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:

• Part C Appeal Request Form

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.

• Initiate a Part C appeal online

Located in Chapter 9, Section 6 of the 2024 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 the Pharmacy Help Desk at:

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.

• Part D Appeal Request Form
• Initiate a Part D appeal online

Located in Chapter 5, Section 4 of the 2024 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 1-844-232-2313, 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

Chapter 9, Section 6 of the 2024 Evidence of Coverage: Your Part D prescription drugs: How to ask for a coverage decision or make an appeal of a coverage decision

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.

• Coverage Determination Request Form
• Initiate a Part D decision online - coming soon

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, 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 1-844-232-2313
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 2024 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:

• 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:

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 2024 Evidence of Coverage

• Section 4 - A guide to the basics of coverage decisions and appeals.
• Section 5 - Your medical care: How to ask for a coverage decision or make an appeal of a coverage decision
• Section 6 - Your Part D prescription drugs: How to ask for a coverage decision or make an appeal of a coverage decision.
• Section 7 - How to ask us to cover a longer inpatient hospital stay if you think you are being discharged you too soon.
• Section 8 - How to ask us to keep covering certain medical services if you think your coverage is ending too soon.
• Section 9 - Taking your appeal to Level 3 and beyond.
• Section 10 - How to make a complaint about quality of care, waiting times, customer service, or other concerns.