If you requested a coverage determination and your request was not approved, you may appeal this decision. Below, you’ll find all the information you need to appeal.
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Medicare Drug Grievances and Appeals
Prescription Drug Grievances and Appeals Information
If you requested a coverage determination and your request was not approved, you may appeal this decision by using this form:
Redetermination (Appeals) About Part D Prescription Drugs
Y0026_127139_NM, Last Updated: 01/2021
Solicitud de Redeterminación de Denegación de Medicamento de Receta de Medicare
Y0026_127139_NM, Last Updated: 01/2021
Fill out the form and send it to us as a standard or expedited appeal within 60 calendar days from the date of the notice of the coverage determination (except when the filing time frame is extended). You need to include the following information with your written appeal:
First name, last name, address, phone number, date of birth, and ConnectiCare ID number
The name of the prescription drug you want us to cover
Reason why you are appealing
Your signature, or if someone is acting on your behalf, a completed appointment of representative form CMS-1696 or a written equivalent (if it was not submitted with the coverage determination)
You should send supporting documentation, including medical records, with your appeal request.
You, your appointed representative or your prescribing physician may request ConnectiCare expedite a coverage determination when you or your physician believes that waiting for a decision under the standard time frame may place your life, health, or ability to regain maximum function in serious jeopardy. A claim for payment for prescription drugs that you have already received will not be expedited.
You can submit your Expedited Redetermination Appeal request to us in one of the following ways:
- CALL 800-224-2273 (TTY: 711). From Oct. 1 to March 31, you can call us seven days a week from 8 a.m. to 8 p.m. From April 1 to Sept. 30, you can call us Monday through Saturday from 8 a.m. to 8 p.m.
- FAX - 800-867-6674
- WRITE -
- ConnectiCare
Part D Expedited Grievances and Appeals
175 Scott Swamp Road
P.O. Box 4010
Farmington, CT 06034
Attention: Medicare Appeals Department
- ConnectiCare
You can submit your Standard Redetermination Appeal request to us in one of the following ways:
- CALL - 800-224-2273 (TTY : 711). From Oct. 1 to March 31, you can call us seven days a week from 8 a.m. to 8 p.m. From April 1 to Sept. 30, you can call us Monday through Saturday from 8 a.m. to 8 p.m.
- FAX - 800-867-6674
- WRITE -
- ConnectiCare
Part D Grievances and Appeals
175 Scott Swamp Road
P.O. Box 4010
Farmington, CT 06034
Attention: Medicare Appeals Department
- ConnectiCare
- Email - PartDStandardAppeals@ConnectiCare.com
You have the right to file a grievance (complaint) with us if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for the state of Connecticut. Please refer to the Evidence of Coverage (EOC) for the Beneficiary and Family Centered Care Quality Improvement Organization (Also known as BFCC-QIO) contact information.
Make sure to include the following information in your grievance:
First name, last name, address, phone number, date of birth, and ConnectiCare ID number
Reason why you are filing a grievance
Your signature, or if someone is acting on your behalf, a completed Appointment of representative form CMS-1696 or a written equivalent
You should send any supporting documentation, including medical records, with your grievance.
You can submit your grievance to us in one of the following ways:
- CALL - 800-224-2273 (TTY : 711). From Oct. 1 to March 31, you can call us seven days a week from 8 a.m. to 8 p.m. From April 1 to Sept. 30, you can call us Monday through Saturday from 8 a.m. to 8 p.m.
- FAX - 800-867-6674
- WRITE
- ConnectiCare
Part D Grievances and Appeals
175 Scott Swamp Road
P.O. Box 4010
Farmington, CT 06034
Attention: Medicare Appeals Department
- ConnectiCare
You can also submit an online complaint to Medicare.
MY COVERAGE
Drugs Covered by Medicare Advantage Plans
Find the list of drugs covered by your ConnectiCare plan (also known as a “formulary”) below.
YOUR MEDICATION
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MTM PROGRAM
Medication Therapy Management
Find out if you qualify for this service program which is provided at no additional cost for eligible ConnectiCare Medicare Advantage plan members who have Part D prescription drug coverage.
Last Update 10/01/2023
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