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Prescription drug appeals & grievances

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
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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
1-800-224-2273 (TTY users: 1-800-842-9710) between 8:00 a.m. and 8:00 p.m. seven days a week

FAX
1-800-867-6674

WRITE
ConnectiCare
Part D Expedited Grievances and Appeals
P.O. Box 4010
Farmington, CT  06034
Attention: Medicare Appeals Department



You can submit your Standard Redetermination Appeal request to us in one of the following ways:

CALL
1-800-224-2273 (TTY users: 1-800-842-9710) between 8:00 a.m. and 8:00 p.m. seven days a week

FAX
1-800-867-6674

WRITE
ConnectiCare
Part D Expedited Grievances and Appeals
P.O. Box 4010
Farmington, CT  06034
Attention: Medicare Appeals Department


Understanding grievances (complaints) for Part D Prescription Drugs 

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 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
1-800-224-2273 (TTY users: 1-800-842-9710) between 8:00 a.m. and 8:00 p.m. seven days a week

FAX
1-800-867-6674

WRITE
ConnectiCare
Part D Expedited Grievances and Appeals
P.O. Box 4010
Farmington, CT  06034
Attention: Medicare Appeals Department

You can also submit an online complaint to Medicare.



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Last Update 11/26/2018

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