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1-877-353-0188 (Toll-free)
TTY/TDD 711
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1-877-353-0185 (Toll-free) 
TTY/TDD 711

Pharmacy Drug Grievances & Appeals (Redetermination)

Coverage Determination | Appeals (Redetermination) | Medicare Part D Forms | CMS Best Available Evidence Policy

Coverage Determination, including exceptions

What is a coverage determination?
A coverage determination is a decision we make about your benefits and coverage or about the amount we will pay for your medication. We are making a coverage decision whenever we decide what is covered for you and how much we pay.

An exception is a special request for the plan to cover a drug or remove restrictions from a drug.

Who can ask for a coverage determination?
You, your doctor, or your representative can do this. If you want to know if we will cover a drug before you receive it, you or your representative can ask us to make a coverage decision for you. If you are requesting an exception, your doctor or other prescriber must give us a statement that explains the medical reason for requesting an exception.

You may appoint an individual to act as your representative to request a coverage decision for you by filling out a personal representative authorization form. (To get the form, call Member Services and ask for the "Appointment of Representative" form. It is also available on Medicare's website at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf.*)

* Please note: By clicking on this link you will be leaving the Senior Whole Health of New York website.

How to request a coverage determination for a medication you want.
Start by calling, writing, or faxing our plan to make your request:

  • CALL:
    • 1-888-794-7268 (Toll-free) or TTY/TDD 711
  • FAX:
    • 1-888-251-7823
  • WRITE:
    • Senior Whole Health
      Attention: Pharmacy Department
      58 Charles Street
      Cambridge, MA 02141
How long will it take to get a decision?
A standard coverage decision means we will give you an answer within 72 hours after we receive your request.

If your health requires it, ask us to give you a "fast coverage decision." A fast coverage decision means we will answer within 24 hours.
  • To get a fast organizational decision, you must meet two requirements:
    • You can get a fast decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast decision if your request is about payment for medical care you have already received.)
    • You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.
  • If your doctor tells us that your health requires a "fast coverage decision," we will automatically agree to give you a fast coverage decision.
  • If you ask for a fast coverage decision on your own, without your doctor's support, we will decide whether your health requires that we give you a fast coverage decision.
If we say no, you have the right to ask us to reconsider – and perhaps change – this decision by making an appeal. Making an appeal means making another try to get the drug coverage you want.

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Appeals (Redetermination)

What is an appeal?
If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

Who can file an appeal?
You may file an appeal, someone else may file the appeal on your behalf, or your doctor (or other prescriber) may file an appeal. You may appoint an individual to act as your representative to file an appeal for you by filling out a personal representative authorization form. (To get the form, call Member Services and ask for the "Appointment of Representative" form. It is also available on Medicare's website at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf.*)

* Please note: By clicking on this link you will be leaving the Senior Whole Health of New York website.

When can an appeal be filed?
You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision.

How to request an appeal for a medication you want.
Start by calling, writing, or faxing our plan to make your request for us to provide coverage for the drug you want.
  • CALL:
    • 1-877-353-0185 (Toll-free), TTY/TDD 711
  • FAX:
    • 1-888-251-7823
  • WRITE:
    • Senior Whole Health
      Attention: Pharmacy Dept.
      58 Charles Street
      Cambridge, MA 02141

How long will it take to get an appeal decision?
If you are requesting a standard appeal, your request must come in writing. If we are using the standard deadlines, we must give you our answer within 7 calendar days after we receive your appeal.

If we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it. The requirements for getting a "fast appeal" are the same as those for getting a "fast coverage decision".

What happens next?
If we say no to your appeal, you must decide if you want to continue with the appeals process and make another appeal.

The written notice we send you will include instructions on how to make a Level 2 Appeal with the Independent Review Organization. These instructions will tell who can make this Level 2 Appeal, what deadlines you must follow, and how to reach the review organization.

For more information please refer to your Medicaid Handbook and Evidence of Coverage.

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Medicare Part D Forms

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CMS Best Available Evidence Policy

Please click on the link below to read the Centers for Medicare & Medicaid Services policy on Best Available Evidence.

CMS Best Available Evidence Policy* 

* Please note: By clicking on this link you will be leaving the Senior Whole Health of New York website. 

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Last Updated 02/06/2018
H5992_2017_099 Approved 11/04/2016