Affinity Health Plan

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  • Pharmacy Grievance and Appeal Rights

    A grievance is a complaint about any problem you had with Affinity or one of our network pharmacies. Grievances do not relate to payment for or approval of a prescription drug, which are known as coverage determinations.

    If you (your appointed representative) have a grievance, please call our Customer Service number at 1-866-362-4002, 24 hours a day, seven days a week. TTY users can call 1-866-236-1069. We will try to resolve your complaint over the phone. You may also fax your grievance to 1-866-633-7673 or mail it to the following address:

    CVS Caremark Inc
    Part D Services
    MC109
    P.O. Box 52000
    Phoenix, AZ 85072-2000

    Expedited Grievances
    If you are grieving the decision by Affinity not to expedite an initial determination or an appeal, you can request an expedited grievance. In these situations, Affinity will respond to you within 24 hours.

    Appeals
    Once Affinity notifies you of a decision regarding a coverage determination request, you may or may not agree with it. You (or your authorized representative) can ask us to reconsider our decision. This is known as filing an appeal. Similar to coverage determinations, there is a fast track and routine process for handling appeals. The chart below explains how these different time frames work.

    You have a right to appeal if you think Affinity:

    • Decided not to cover a drug, vaccine, or other Part D benefit
    • Decided not to reimburse you for a Part D drug that you paid for
    • Reimbursed you less than you feel you should have received
    • Asked you to pay a different cost-sharing amount than you think you are
    • Required to pay for a prescription
    • Denied your exception request

    We will consider your appeal thoroughly and promptly. The time frames listed above will give you an idea of when you can expect a response from Affinity. It is important to let us know as soon as possible that you wish to file an appeal. If you wish to file a standard appeal, you must send written request within sixty (60) days from the date of the notice of coverage determination.

    You may fax your Appeal request to 1-866-633-7673 or mail it to the following address:

    CVS Caremark Inc
    Part D Services
    MC109
    P.O. Box 52000
    Phoenix, AZ 85072-2000

    To request a fast appeal, you may call 1-866-362-4002, 24 hours a day, seven days a week. TTY users can call 1-866-2356-1059.

    If your complaint is regarding a quality of care issue (for example, you believe our pharmacist provided you with the incorrect dose of a prescription) you may also file a complaint with the Quality Improvement Organization (QIO), called Island Peer Review Organization (IPRO) by calling 1-800-331-7767 or for TTY, 1-866-446-3507. A QIO is a group of doctors and health professionals that monitor the quality of care provided to Medicare beneficiaries. The Quality Improvement Organization review process is designed to help stop any improper medical practices.

    Who May Ask for a Grievance or an Appeal?
    You or someone you name to act for you (your appointed representative) may request a grievance or an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others may already be authorized under State law to act for you. Please fill out the Appointment of Representative form and send it to us with your request. You can call us at 1-877-234-4499 or for TTY at 1-800-662-1220 if you need help filling out the form or want to learn more about appointing a representative.

  • H5991_AffinityMedicarePlanWebsite2017 CMS Pending Last updated 10/03/2016