The resource information linked to the CommunityCare Senior Health Plan formulary web page pertaining to grievances, coverage decisions (including exceptions), and appeals processes are taken directly from the 2024 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 Platinum, Platinum Plus or Silver Plus, please click the link.
Click on a topic below for more information.
Located in Chapter 9, Section 10 of the 2024 Evidence of Coverage: Making Complaints
To submit a grievance verbally, contact Customer Service at:
(918) 594-5323 or 1-800-642-8065,
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:
Senior Health Plan
Attn: Grievance and Appeals Department
P.O. Box 3327, Tulsa, OK 74101-3327
Fax Number: 918-879-4048
In person:
CommunityCare Senior Center
4720 S. Harvard, Suite 101
Tulsa, OK 74135
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.
To request a coverage decision verbally, contact Customer Service at 1-800-642-8065
or (918) 594-5323 (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:
Senior Health Plan
Attn: Customer Service
P.O. Box 3327, Tulsa, OK 74101-3327
Fax Number: 918-594-5250
In person:
CommunityCare Senior Center
4720 S. Harvard, Suite 101
Tulsa, OK 74135
Located in Chapter 9, Section 6 of the 2024 Evidence of Coverage: "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 1-844-232-2311, 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
A letter or the standardized Medicare Prescription Drug Coverage Determination Form may be used to submit a request. Click on the link to print this form.
Enrollees and Providers: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:
To submit an appeal request in writing, send to:
Senior Health Plan
Attn: Grievance and Appeals Department
P.O. Box 3327, Tulsa, OK 74101-3327
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 1-800-642-8065
or (918) 594-5323 (local);
TTY/TDD: 1-800-722-0353.
Monday through Friday from 8:00 am to 8:00 pm.
Fax Number: 918-879-4048
In Person:
CommunityCare Senior Center
4720 S. Harvard, Suite 101
Tulsa, OK 74135
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 2024 Evidence of Coverage: Your Part D prescription drugs: How to ask for a coverage decision or make an appeal
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 1-844-232-2311, 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 2024 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.
For a prescribing physician to submit a supporting statement verbally, contact CVS Caremark Part D Exceptions Department at 1-844-232-2311, 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
| 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 | ||
|---|---|---|
|
Senior Health Plan Attn: Grievance and Appeals Department P.O. Box 3327 Tulsa, OK 74101-3327 Fax Number: 918-879-4048 |
||
| For Part C Coverage Determinations and Exceptions |
Senior Health Plan Attn: Customer Service P.O. Box 3327 Tulsa, OK 74101-3327 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 |
|
| In person | ||
| 4720 S. Harvard, Suite 101, Tulsa, OK 74135 (Senior Center) | ||