If a participant believes that CVS Caremark incorrectly denied all or part of a prescription drug claim, he has the right to obtain a full and fair review. A request for review must be made in writing to CVS Caremark.
The participant has 180 days from receiving notice of denial from CVS Caremark to request a review. The participant may provide additional information that relates to the denied claim. If the participant fails to request a review within this timeframe, the right to review is forfeited.
After the claim has been reviewed, if benefits are again denied, the decision will be sent to the participant in writing. The letter will include the reason(s) why benefits are denied, with reference to the Plan provisions on which the decision is based.
If, after following the appeal procedure, the participant still disagrees with the determination, a second level appeal may be submitted in writing to CVS Caremark within 180 days after receiving the initial denial from CVS Caremark. The second level appeal decision will conclude all appeals with CVS Caremark.
Within four months after the date of receipt of a final internal denial of a claim, the participant may file a request for an independent review. An independent review is available when the final denial involves an issue of medical judgement (including, but not limited to, medical necessity, appropriateness, health care setting, level of care, effectiveness, or whether a treatment is experimental or investigational), or rescission. The participant will be required to authorize the release of any medical records that may be required to be reviewed for the purpose of reaching a decision on the external review. The request must be made by contacting CVS Caremark and must include all information pertinent to the denied claim. An external review decision is binding on the participant except to the extent the participant has other remedies available under applicable federal or State law.
Failure to request a review within the above-referenced time frame and in accordance with the procedures will result in the participant's right to an appeal and rights to sue being forfeited. Note: A participant may request an independent review during any part of the Appeal Process.