When you or a loved one is prescribed a medication, the last thing you want to worry about is whether it will be covered. If you have recently experienced an insurance denial or an "adverse benefit determination," please know that this is not always the final decision. You have a right to an appeal, and our team is dedicated to supporting you through every step of this process with care, transparency, and clarity.
The guidelines below outline how the CVS Caremark appeals program works and what you can expect as we work together toward a resolution.
Understanding Your Denial
Before diving into an appeal, it helps to understand what type of request was originally denied, as this determines your path forward:
- Clinical Denials: These occur when a medication requires a Prior Authorization (PA), step therapy, or specific quantity limit exception, and the initial review determined that the plan’s clinical criteria were not fully met.
- Non-Clinical Denials: These happen when a medication or medical device is completely excluded from your plan's formulary or benefits design.
Your Right to Know: Every denial letter sent to you and your doctor will clearly explain the specific reasons for the decision, reference the exact plan provisions used, and include step-by-step instructions on how to file an appeal.
How to File an Appeal
If you and your doctor believe your prescribed medication is necessary, you have 180 days from the date you received the denial notification to submit an appeal.
Appeals can be submitted by you, your doctor, or an authorized representative through the following channels:
- By Phone (Urgent Only): Urgent appeals can be initiated directly over the phone by calling CVS Caremark Customer Care.
- By Fax or Mail (Standard/Non-Urgent): Standard appeals should be submitted in writing using the fax number or mailing address provided on your denial letter.
Helpful Information to Include
To give your appeal the best possible chance of success, your doctor can submit supporting medical evidence. This may include:
- A written Letter of Medical Necessity from your practitioner.
- Relevant medical records, laboratory results, or progress notes.
- A copy of the original denial letter or prescription payment receipts.
The Appeal Levels and Timelines
Once CVS Caremark receives an appeal, it is time-stamped and assigned to an appropriately qualified reviewer who has no personal or financial conflict of interest with the case.
How your appeal is handled depends on whether your request is urgent or non-urgent:
Urgent Appeals (Combined Review)
If your doctor indicates that waiting for a standard decision could seriously jeopardize your health, your request will be treated as an Urgent Pre-Service Appeal.
- Timeline: CVS Caremark will review and deliver a decision within 72 hours.
- The Process: To protect your health and save time, CVS Caremark automatically combines the First-Level and Second-Level clinical reviews. If the first-level review cannot be approved, it immediately and automatically shifts to a Medical Necessity review so a final decision can be reached within the 72-hour window.
Standard (Non-Urgent) Appeals
For standard medical requests, the review process depends on your specific employer plan design:
| Appeal Type | Description & Process | Decision Timeline |
| First-Level Clinical Appeal | Your case is evaluated against predetermined medical criteria alongside any new supporting documentation your doctor provides. | 15 days (for plans with 2 levels)
30 days (for plans with 1 level) |
| Second-Level Medical Necessity Appeal | If a First-Level appeal is upheld (denied), you can request this second review. Your file is evaluated by an independent Medical Necessity Review Organization (MNRO) where an independent physician reviewer assesses current medical literature and your records. | 15 days |
| Non-Clinical Appeal | A single-level review that checks your request strictly against the written terms of your plan's formulary or benefits design (does not assess medical necessity). | 15 days (Pre-Service)
30 days (Post-Service) |
What Happens Next?
Once a decision is rendered, it will be communicated to you and your doctor in writing, using clear, easy-to-understand language.
- If Approved: Overrides will be entered into the pharmacy system, a test claim will be run to ensure it processes seamlessly, and you will be clear to fill your prescription.
- If Denied: The letter will detail your remaining options, which may include moving to a Second-Level review, requesting an Independent External Review, or exploring a covered alternative drug with your doctor.
A Note on Confidentiality: Your privacy is incredibly important to us. All appeal documentation is handled with the strict compliance required by federal and state regulations to safeguard your identity and prescription history.
If you are unsure of your plan's specific level of appeals or need help starting this process, please reference "Prior Authorization FAQ for Members.pdf" for general troubleshooting, or call the Customer Care number on the back of your member ID card. We are here to support you every step of the way.