2025 Plan Documents and Information

Plan Documents and Directories

Annual Notice of Change
Evidence of Coverage
Summary of Benefits
Provider Directory
Pharmacy Directory
Formulary

Medical Plan Information

Expedited Determinations
Medicare Part C Transition Policy
Aggregate Number of Prior Authorizations, Appeals, and Grievances
Appeals for Medical Benefit (Healthcare Services or Part B Drugs)
Part B Step Therapy
Complaints and Grievances

Prescription Drug Information

Prior Authorization
Coverage Determinations and Appeals for Part D Drug
Medicare Prescription Payment Plan
Medicare Part D Drug Transition Policy
Quality Assurance
Medicare Part D Utilization Management
Prescription Mail-order Services
Medication Therapy Management
Drug Management Program
Part D Forms

Other Plan Information

Appointment of Representative
Getting Care During a Disaster
Best Available Evidence
Disenrollment Information
Payment Information

Plan Documents and Directories

Annual Notice of Change

Back to top

Evidence of Coverage

Back to top

Summary of Benefits

Back to top

Provider Directory

Provider Directories

Provider Directory - Indiana, Ohio (Cincy/Dayton), Kentucky

Provider Directory - NE Ohio, NE Indiana, NW Ohio, SE Michigan

Provider Directory - NW Ohio, SE Michigan

Provider Directory - PPO

Online Provider Directory

Dental

Paramount Elite - Dental Provider Directory

Online Dental Directory

Hearing

Paramount Elite - Hearing Aid Directory

Online Hearing Directory

Vision

Paramount Elite - Vision Hardware Directory

Online Vision Directory

Back to top

Pharmacy Directory

Members have access to network pharmacies for their prescription drug benefits. Pharmacies located near you can be found in our Pharmacy Directory. Pharmacy network listings may change throughout the year. However, you can always find the most current pharmacy listing online by using our Find a Pharmacy tool.

Online Pharmacy Locator

Paramount Elite Pharmacy Directory

Note: Our pharmacy network is subject to change at any time; however, you will receive notice before any network changes.

Back to top

Formulary

If your plan Medicare Plan includes prescription drug coverage, make sure you look for your medications on our prescription drug list (formulary). For a complete prescription drug list, download a copy of our formulary:

Medicare Part D Comprehensive Formulary: Preferred, Standard, Prime and Essential Plans

Medicare Part D Comprehensive Formulary: Enhanced and Prescription Drug (Employer PDP) Plan

Back to top

Medical Plan Information

Expedited Determinations

An expedited determination (fast coverage decision) can be requested for healthcare services or Part B drugs (called an “organization determination”) or for Part D prescription drugs (called a “coverage determination”). You can ask for an expedited determination if you meet these two requirements:

  • You are asking for an expedited determination (fast coverage decision) for healthcare services, Part B drugs or Part D drugs that you have not yet received.
  • Your provider tells Paramount that if we take the standard 14 days to make a decision, it could cause serious harm to either your health or your ability to function. Please note that if your provider requests an expedited determination (a fast coverage decision), the request will be expedited automatically.

Expedited Organization Determinations - Part B Drugs

When you make a request for coverage for healthcare services or Part B drugs, this is called an “organization determination.” Paramount will make a decision for your organization determination as quickly as your health condition requires – but no later than 72 hours after receiving a valid request.

You (or your appointed representative) and your requesting provider will be notified of the decision whether approved or denied. Paramount will call you (or your appointed representative) and your requesting provider with the coverage decision, and a letter will be mailed within three (3) calendar days of the telephone call. If the request was denied, the denial letter will explain why the coverage request was denied and it will list your rights and instructions if you wish to file an appeal (also called a reconsideration).

How to Request an Expedited Organization Determination - Part B Drugs

If your health condition requires a fast coverage decision, it would be best to have your provider send us a request for an expedited organization determination (fast coverage request) so that we have the medical information that we need to make a decision as quickly as possible. Please complete any of the following to ask for an Expedited Organization Determination:

  • Fax a prior authorization request to Paramount’s Utilization Management team at 419-887-2028
  • Call Paramount’s Utilization Management team at 419-887-2520, or toll-free 800-891-2520
  • Complete the Member Organization Determination form

In the event that a fast coverage request (expedited organization determination) does not meet the criteria for expedited handling, Paramount will automatically transfer and process the request as a standard organization determination (non-urgent coverage request) using the 14-calendar day timeframe, which applies for standard organization determinations.

If Paramount transfers your fast coverage request (expedited organization determination) to the standard processing timeframe, you will be notified by phone and a letter will be mailed to you with an explanation of why your fast coverage request did not meet the criteria for expedited handling. You have the right to file an expedited grievance with Member Services if you disagree with the decision not to expedite the request.

Expedited Organization Determinations - Healthcare/Medical Services

Paramount will make a determination as quickly as your health condition requires – but no later than 72 hours after receiving the request.

You and your requesting provider will be notified of the decision, whether favorable or adverse. Paramount will notify you and your requesting provider of an adverse decision orally, followed by written confirmation mailed to you within three calendar days of the telephone call. The written notice will explain why the determination was denied and your rights to file a reconsideration or an appeal.

How to Request an Organization Determination - Healthcare/Medical Services

To initiate an organization determination, have your provider complete any of the following:

  • Fax a prior authorization request to Paramount’s utilization management team at 419-887-2028.
  • Providers may also submit high-dollar imaging procedures through the web-based prior authorization submission tool McKesson Clear Coverage.
  • Complete the Member Organization Determination form and fax to 419-887-2047

If Your Request to Expedite is Denied

If your request is denied, we’ll call you. Then, within three calendar days, you’ll receive a letter. The letter explains the enrollee’s rights:

  • Paramount will automatically transfer and process your request using the 14-day timeframe for standard determinations. For Part B drugs, Paramount will use the 72-hour timeframe.
  • You have the right to file an expedited grievance if you disagree with the decision not to expedite the determination.
  • You can resubmit a request for an expedited determination. If your provider indicates that the 14-day timeframe could seriously jeopardize your life or health or your ability to regain maximum function, the request will be expedited automatically.
  • The letter will provide instructions about the expedited grievance process and its timeframes.

Back to top

Medicare Part C Transition Policy

Beginning Jan. 1, 2025, if you are a new member of your Medicare Advantage plan (Paramount Elite) and/or to Medicare and are currently undergoing an active course of treatment, you may qualify for a transition period for Medicare Part C covered drugs and services. For some drugs and services, we require additional information from your provider to determine if the drug or service is medically necessary.

We will cover restricted Medicare Part C drugs or services for the first 90 days of your Medicare Advantage plan (Paramount Elite) to ensure you do not experience any disruptions. We will work with your provider to get all the information needed to determine if we will continue coverage.

For more information regarding our Medicare Part C Transition Process, please call Member Services toll free at 1-833-554-2335 (TTY: 711 for hearing impaired).

Your provider can start a determination (also known as an organization determination) by contacting the following organizations:

  • For Part B drugs, have your provider submit a request to Prime Therapeutics
  • For Part C outpatient medical services or items, your provider should fax in the request utilizing one of Paramount prior authorization forms.

For Medicare Part D Transition policy, call our Pharmacy Customer Service team at 1-844-404-7947 (TTY: 1-800-716-3231 for hearing impaired), 24 hours a day, 7 days a week.

Back to top

Aggregate Number of Prior Authorizations, Appeals, and Grievances

As a Medicare Advantage plan, Paramount tracks information related to member appeals and grievances (complaints) processed.  Anyone who is eligible to enroll in a Medicare Advantage plan has the right to ask for information about the number of appeals and grievances that a Medicare Advantage plan receives.  This information is provided upon request and lists the average number of appeals and grievances received per 1.000 members (example: 1 grievance per 1,000 members) during the most recent reporting period, which is based on the calendar year (not based on the last 12 months).  Please contact Member Services and let the representative know that you would like to receive an Appeals and Grievances Data Report for the Paramount Medicare Advantage plans that are offered in your service area. (Ref: Per 42 CFR 422.111(c)(3)).

Back to top

Appeals for Medical Benefit (Healthcare Services or Part B Drugs)

Standard Appeal for Medical Benefit (Healthcare Services or Part B Drugs)

An appeal is something that you have a right to ask for when you want to ask Paramount to review and reconsider its first decision regarding your requested healthcare coverage (pre-service) or claim payment (for services or items received). The appeal process for healthcare services (including durable medical equipment) and Part B drugs is also called a “reconsideration.” The reconsideration process is NOT used to appeal Part D drug coverage or claims.

When a valid Standard Appeal request is received by Paramount, the appeal decision is required to be made as quickly as your health condition requires but no later than the applicable timeframe listed below:

  • 30 calendar days* for a Standard Appeal request for healthcare items or services (see below for Part D and Payment Appeal requests)
  • 7 calendar days for a Part B drug Standard Appeal request

*14 more calendar days may be added to this timeframe (called an “extension”) if you ask for more time or if we need more information that we think may benefit you and support your appeal request, such as medical records (note: This does not apply to Part B drugs). If an extension is taken, written notification will be mailed to you (or your representative) with an explanation of why we think the extension is in your best interest.

When To Request an Appeal for Your Medical Benefit (Healthcare Services or Part B Drugs)

When Paramount sends you a letter or a claim to let you know of its decision to either cover or deny your healthcare services or Part B drugs, that first decision is called an “organization determination.” If you disagree with any organization determination (decision) made by Paramount that is related to the coverage of your healthcare services or Part B Drugs because you believe that the service or Part B drug should be covered, or that the amount of coverage is not correct, please consult your Evidence of Coverage first. If you still disagree with Paramount’s organization determination (decision) after reviewing your EOC, please contact Member Services and request an appeal.

Please Note: If Paramount has not yet made a decision regarding coverage of your requested healthcare services or Part B Drug(s), then you will not be able to request an appeal because you can only ask for an appeal after a decision is made and you disagree with that decision.

If your health condition requires an immediate response for healthcare services or Part B Drugs that you are waiting to receive, please contact Member Services and/or review the section on Requesting An Expedited Appeal. This section only discusses standard appeals, which do not require an immediate decision, based on your perceived health condition or status.

How To Make an Appeal Request for Your Medical Benefit (Healthcare Services or Part B Drugs)

Paramount must receive your request to appeal no later than 65 calendar days from the date noted on your organization determination notice in order to consider your request. Your organization determination notice is the document that Paramount sent to you to let you know its decision regarding your coverage. This notice will either be a letter or an Explanation of Benefits (EOB), depending on whether or not a claim has already been processed. You must use one of the following methods to request an appeal with Paramount for healthcare services or Part B drug decisions:

Call 833-554-2335 to talk with a Member Services representative. Member Services is available Monday – Friday, 8 a.m. – 8 p.m. from April 1 through September 30 (closed Memorial Day, Independence Day and Labor Day). From October 1 through March 31 (closed on Thanksgiving and Christmas), Member Services is available 8 a.m. – 8 p.m., seven (7) days a week. If you use TTY telephone equipment, please call 711.

  • Fax your written appeal request letter to 419-887-2037 Attention: Appeals Coordinator, Member Services Department
  • Mail your written appeal request to: P.O. Box 928, Attn: Appeals Coord., Member Services Dept., Toledo, OH 43697-0928
  • Email your written appeal request to PHCmbrsvcappeals@medmutual.com
  • In person at our Maumee, Ohio, location, Monday – Friday, 8 a.m. - 5 p.m.: Paramount Member Services, 650 Beaver Creek Circle, Suite 100, Maumee, OH 43537

Expedited Appeals for Your Medical Benefit (Healthcare Services or Part B Drugs)

Asking for a fast appeal (expedited reconsideration) means that you (or your appointed representative) or your provider are asking Paramount to make its appeal decision within 72 hours of your fast appeal (expedited reconsideration) request. You (or your appointed representative) or your provider can ask for a fast appeal (expedited reconsideration) for healthcare services or Part B drugs, if these two requirements are met:

  • You are asking for a fast appeal (expedited reconsideration) for coverage of healthcare services or a Part B drug that you have not yet received. (This means that you cannot request a fast appeal (expedited reconsideration) regarding payment for medical care or a Part B drug you have already received.)
  • If we were to use the standard deadline to process your appeal (which is 30 days for healthcare services OR 7 days for Part B drugs), those additional days could result in serious harm to your health or hurt your ability to function.

Sometimes Paramount needs to ask for more information from your provider, so this could delay our decision. If your fast appeal (expedited reconsideration) request is for healthcare services and we think that your provider may provide us with important information to support your request, then Paramount may extend the decision deadline by 14 more days. Please note that Paramount cannot extend the deadline for a fast appeal (expedited reconsideration) decision related to Part B drugs.

If Paramount extends the deadline for making a fast appeal (expedited reconsideration) decision related to coverage for healthcare services (not Part B drugs), we will call you first to let you know, and then a letter will be mailed to you to explain why we think the extension is in your best interest. You have the right to file an expedited grievance with Member Services if you disagree with our decision to extend the deadline for making our decision regarding your fast appeal (expedited reconsideration).

You do not need to know which type of appeal request to ask for. We will help you.

If you call Member Services to file your appeal request, our Member Services representatives will review the details of your appeal request with you (or your representative) to ensure that everything is documented correctly and then your appeal request will be forwarded to the Appeals team for proper classification. As mentioned, you may also file your appeal request by mail, fax, or [secure] email, or in person. We cannot accept any appeal request received via Live Chat.

If your appeal request is not valid for some reason, or if the person who filed the appeal is not properly appointed or authorized to file an appeal request for you, you will receive written instructions on how to correct your appeal request (make it valid).  If we do not receive information or documentation to make your appeal request valid before the deadline, we will send you a Notice of Appeal Dismissal, depending on what is wrong with or missing from your appeal request.

Please note that if your appeal request is received after the appeal filing deadline, which is 65 calendar days after the date of your written notice that included appeal rights, you will receive a Notice of Appeal Dismissal.

If your doctor or other prescriber tells us that your health requires a “fast decision,” we will automatically give you a fast decision. You will be notified by letter if this occurs.

Refer to your plan's Evidence of Coverage for complete guidelines.

You Can Ask Someone to Act on Your Behalf for Standard Appeals

If you would like to name another person to act as your representative so that this person can contact Paramount and CVS Caremark and make requests for you, learn more in the Appointment of Representative section.

You do not need to appoint a representative to act on your behalf, unless you want to.

Payment Appeal Process (does not apply to Standard Appeals)

When a valid Payment Appeal request is received by Paramount, the appeal decision is required to be made no later than the applicable timeframe listed below:

  • 65 calendar days for claims payments already processed and related to healthcare items or services already provided (including Part B drug payments)
  • 14 calendar days for claims payments already processed and related to Part D prescription drugs (excludes formulary exception requests, please see above)
  • If your appeal request is either denied, or if the appeal decision timeframe is not met (including any extension taken), Paramount or CVS (as applicable) must forward your appeal request to an independent review entity (IRE) within 24 hours of either the decision to deny your appeal request or the missed appeal decision deadline, whichever comes first. When your appeal request is transferred to the IRE, this is called “second level appeal.” These rules apply to standard, expedited, and payment appeal requests regardless of whether the appeal request is for prescription drug benefits, Part B drugs, or healthcare items or services.

If your appeal request is forwarded to an IRE (for a second level appeal), you will receive written notification from the IRE that describes your second level appeal request and the required deadline for the IRE to make its decision. The IRE will then issue its second level appeal decision within the allowed timeframe for your type of appeal request and will send you written notification of its decision, including any additional appeal rights that are available to you. If you have not received timely notification of a decision for any appeal request within 5 days after the appeal decision deadline for your appeal request has passed, please contact Member Services for assistance. You may view your plan's Evidence of Coverage for a complete description of the appeals process. 

Back to top

Part B Step Therapy

Some medically administered Part B drugs may have additional requirements or limits on coverage. These requirements and limits may include step therapy, where Paramount requires you to first try certain preferred drugs to treat your medical condition before covering another non-preferred drug for that condition.

For example, if Drug A and Drug B both treat your medical condition, Paramount may prefer Drug A, and require you to try it first. If Drug A does not work for you, Paramount will then cover Drug B. The listed preferred products should be used first. An exception process is in place for specific circumstances that may warrant a need for a non-preferred product.

Part B Step Therapy Requirements

Back to top

Complaints and Grievances

Paramount’s healthcare services and prescription drug plan grievance process is designated to address enrollee coverage issues, complaints and problems.

How to File a Grievance

If you would like to make a complaint (which is what we refer to as “file a grievance”) about any of our services, your benefit package, or the treatment you received from a provider, a facility, or a pharmacy, you or your appointed representative can file a grievance. You (or your appointed representative) can also file a grievance if you discover an error in our records that you would like to have corrected.

You can file your grievance (make your complaint) with us by phone or in writing by fax, letter, or email (our contact information appears below), however, we need to be notified within 60 days after you experienced the problem, were unhappy with services, or found the error.

Your grievance (complaint) can include any dissatisfaction that you have with your Medicare Advantage plan benefits, any of the services or communications that we have provided to you, and/or anything that you experienced related to your healthcare that you believe should have been handled differently. This includes any grievance (complaint) that you have about the quality of the care you received from a provider (doctor, nurse, hospital, urgent care, and any of their representatives) or the way a pharmacy handled filling your prescription.

Please note that we also have an appeal process that you will need to use when your grievance (complaint) is regarding the amount that was paid on a claim or the way your benefits were applied. You would also need to file an appeal if you disagree with a decision to deny a request for healthcare services, Part B drugs, or Part D prescription drugs.

If your grievance (complaint) is about your request for coverage or any payments that were made or not made by the plan, you should look at the section on this site regarding making an appeal first. For more information on making a complaint (grievance) or filing an appeal about your healthcare, Part B drugs, or Part D prescription drugs, please refer to your Evidence of Coverage.

Paramount is able to accept a grievance (complaint) verbally or in writing directly from you (or your appointed representative) within the timeframe stated above. Complaints that qualify as standard grievances will be responded to within 30 calendar days of receipt. Complaints that qualify as expedited grievances will be responded to within 24 hours of receipt. Either Paramount or the person who filed the grievance (who may be you or your appointed representative) can add a 14-calendar day extension to give us more time to resolve or respond to your grievance. If we extend the timeframe, a letter will be mailed to the person who filed the grievance (who may be you or your appointed representative). This letter will explain the reason for the delay and why the delay (extra time for investigation) will help allow us to resolve the grievance in your best interest. Again, please refer to your plan’s Evidence of Coverage for additional information and a complete description of the complaint (grievance) process.

To file a grievance:

Phone

Call 567-585-9888 or toll free at 833-554-2335 to talk with a Member Services representative. If you use TTY telephone equipment, call 711.

Member Services representatives are available:

  • April 1 through September 30: Monday – Friday, 8 a.m. – 8 p.m. (closed Memorial Day, Independence Day and Labor Day)
  • October 1 through March 31: seven days a week, 8 a.m. – 8 p.m. (closed on Thanksgiving and Christmas)

Fax

Fax your written complaint letter to 419-887-2037, Attention: Grievances, Member Services

Mail

Mail your written complaint letter to:

Paramount
Attention: Grievance Coordinator, Member Services Dept.
P.O. Box 928
Toledo, OH 43697

Email

Email your written request to: PHCMbrSvcAppeals@MedMutual.com.

Online

File a grievance using the Medicare Electronic Complaint form [OC1]. Your complaint will be sent to us by Medicare.

View your plan's Evidence of Coverage for a complete description of the grievance process.

Back to top

Prescription Drug Information

Prior Authorization

Prior Authorization Criteria

Step Therapy Criteria 

Drug classes with preferred products:

Back to top

Coverage Determinations and Appeals for Part D Drug

Some drugs may require a Prescription Drug Coverage Determination before your prescription can be filled by the pharmacy. Some drugs may not be on the formulary and other covered drugs may have requirements and limits.

View your plan's Evidence of Coverage for complete guidelines.

Coverage Determination or Exception Requests

You may ask Paramount to make an exception to the coverage rules. The types of exceptions you can request are:

  • Prior Authorization
  • Step Therapy
  • Quantity Limit
  • Formulary Exception
  • Tiering Exception

To Initiate a Coverage Exception Request

You, your appointed representative or your prescribing provider may contact Paramount’s prescription drug benefit manager, CVS Caremark, in the following ways:

  • Call 855-749-0851 to speak with a CVS Caremark customer service representative 24 hours a day, seven days a week. TTY users can call 711.
  • Fax a request to CVS Caremark at 855-633-7673855-633-7673, Attention: CVS Caremark Part D Services Appeals and Exceptions.
  • Submit an online Coverage Determination Form directly from our website.
  • Send a written request to: CVS Caremark Part D Services Appeals and Exceptions, P.O. Box 52000 MC 109, Phoenix, AZ 85072-2000
  • Email Paramount.MemberServices@MedMutual.com

When To Request an Appeal for Part D Prescription Drugs

When CVS Caremark sends you a letter or a claim to let you know of its decision to either cover or deny your Part D prescription drugs, that first decision is called a “coverage determination.” If you disagree with any decision made by CVS Caremark that is related to the coverage of any of your Part D prescription drugs, please consult your current Paramount Drug Formulary (also called the List of Covered Drugs) first. If you still disagree with CVS Caremark’s decision after reviewing your current Drug Formulary, please contact CVS Caremark and request an appeal.

Please note that if CVS Caremark has not yet issued a decision regarding coverage of your requested Part D prescription drug(s), then you will not be able to request an appeal.

If your health condition or plan of care requires an immediate response regarding coverage of a Part D prescription drug that you are waiting to receive, please contact CVS Caremark by phone at 855-749-0851 and/or review the section on requesting an Expedited Appeal. This section only discusses Standard Appeals, which do not require an immediate decision, based on your perceived health condition or health status.

Standard Appeal – Part D Prescription Drugs

Paramount has contracted with CVS Caremark to provide services as its Pharmacy Benefit Manager (PBM). This means that CVS Caremark has been given the authority to make decisions for Paramount regarding your prescription drug coverage. An appeal is something that you have a right to ask for when you want CVS Caremark to review and reconsider its first decision (referred to as a “coverage determination”) regarding your requested Part D prescription drug coverage. The appeal process for Part D prescription drugs is also called a “redetermination.” The redetermination process is NOT used to appeal healthcare services or Part B drugs.

When a valid Standard Appeal request for a Part D drug is received by CVS Caremark, the appeal decision is required to be made as quickly as your health condition requires but no later than the timeframe listed below:

  • 7 calendar days for Standard Appeal request for a prescription drug (Part D), including a request for a formulary exception.

How To Make an Appeal Request for Part D Prescription Drugs

CVS Caremark must receive your request to appeal no later than 65 calendar days from the date noted on your coverage determination notice to consider your request. Your coverage determination notice is the document that was sent informing you of the decision regarding your coverage. This notice will be a letter. You must use one of the following methods to request an appeal with CVS Caremark for Part D prescription drug decisions:

  • Call 855-749-0851 to talk with a CVS Caremark customer service representative. You may call any time, 24 hours a day, seven (7) days a week. If you use TTY telephone equipment, please call 711.
  • If you have NOT ALREADY PAID for your Part D prescription drug out of pocket, you may FAX your written appeal request letter to 1-855-633-7673, Attention: CVS Caremark Part D Services Appeals and Exceptions
  • You may submit your request using the online CVS Caremark Request for Redetermination form directly from this website.
  • If you have not already paid for your Part D prescription drug out of pocket, you may mail your written appeal request to: CVS Caremark, Appeals Dept., MC109, PO Box 52000, Phoenix, AZ 85072-2000.
  • If you have already paid for your Part D prescription drug out of pocket and would like to request reimbursement, you may fax your written reimbursement request to 855-230-5549, Attention: CVS Caremark Part D Services Appeals and Exceptions Paper Claims
  • If you have already paid for your Part D prescription drug out of pocket and would like to request reimbursement, you may mail your written reimbursement request to: CVS Caremark, Part D Services Appeals and Exceptions, Paper Claims, PO Box 52066, Phoenix, AZ 85072-2066.

In the event that a fast appeal (expedited reconsideration) request does not meet the criteria for expedited handling, Paramount will automatically transfer and process the appeal request as a standard reconsideration (non-urgent appeal request), which means that we will use the 30-calendar day timeframe (for healthcare services) or 7-calendar day timeframe (for Part B drugs).

If Paramount transfers your fast appeal (expedited reconsideration) request to the standard processing timeframe, you will be notified by phone first and then a letter will be mailed to you with an explanation of why your fast appeal (expedited reconsideration) request did not meet the criteria for fast (expedited) handling. You have the right to file an expedited grievance with Member Services if you disagree with the decision not to expedite the request.

If a request for a fast appeal (expedited reconsideration) is valid and Paramount does not extend the decision deadline or attempt verbal notification of its decision before the 72-hour deadline, Paramount is required to forward the appeal request to Level 2 of the appeals process, where it will be reviewed by an independent outside organization.

Expedited Appeals for Part D Prescription Drugs

A fast decision means CVS Caremark will answer your appeal within 72 hours after receiving your prescriber's statement supporting your request. To get a fast decision, you must meet two requirements.

You can get a fast decision only if:

  • You are asking for a drug you have not yet received. (You cannot get a fast decision if you are asking us to pay you back for a drug you have already bought.)
  • You can only request an expedited coverage decision if using the standard deadlines would likely result in serious harm to your health or hurt your ability to function.

How to Request an Expedited Appeal for Part D Prescription Drugs

You have several ways to request an expedited appeal:

  • Call 567-585-9888 or toll free at 855-749-0851 to speak with a CVS Caremark customer service representative 24 hours a day, seven days a week. TTY users can call 711.
  • Fax a request to 1-855-633-7673, Attention: CVS Caremark Part D Services Appeals and Exceptions.
  • Fax a reimbursement request to 1-855-230-5549, Attention: CVS Caremark Part D Services Appeals and Exceptions Paper Claims.
  • Send a written request to: CVS Caremark Part D Services Appeals and Exceptions P.O. Box 52000 MC 109, Phoenix, AZ 85072-2000.
  • Send a written reimbursement request to: CVS Caremark Part D Services Appeals and Exceptions Paper Claims P.O. Box 52066, Phoenix, AZ 85072-2066.
  • Submit an online Redetermination Form directly from our website.

Back to top

Medicare Prescription Payment Plan

Overview

The Medicare Prescription Payment Plan is a new payment option that works with your current Medicare Part D drug coverage to help you manage your out-of-pocket Medicare Part D drug costs by spreading them across the calendar year (January-December). Starting in 2025, anyone with a Medicare Part D drug plan or Medicare drug coverage can use this payment option. All plans offer this payment option and participation is voluntary.

If you select this payment option, you will get a bill from Paramount to pay for your prescription drugs (instead of paying the pharmacy). There is no cost to participate in the Medicare Prescription Payment Plan.

Learn More

How the Program Works

Once Paramount reviews your participation request, we’ll send you a letter confirming your participation in the Medicare Prescription Payment Plan. When you get a prescription for a drug covered by Part D (including mail order and specialty pharmacies), we will automatically let the pharmacy know that you’re participating in this payment option. You won’t pay the pharmacy for the prescription. Instead, Paramount will send you a bill for the amount you owe, and this will include information on when the bill is due, and how to make a payment.

Your monthly bill is based on what you would have paid for any prescriptions you get, plus your previous month’s balance (if applicable), divided by the number of months left in the year. All plans use the same formula to calculate your monthly payments.

Future payments may increase when you fill a new prescription (or refill an existing prescription) because as new out-of-pocket costs get added to your monthly payment, and there are fewer months left in the year to spread out your remaining payments.

Even though you won’t pay for your drugs at the pharmacy, you’re still responsible for the costs. If you want to know what your drug will cost before you take it home, call CVS toll free at 1-855-749-0851 (TTY: 711).

The prescription drug law caps your Medicare drug coverage annual out-of-pocket maximum at $2,000 in 2025. This applies to everyone with Medicare drug coverage, even if you don’t participate in the Medicare Prescription Payment Plan. This payment option might help you manage your monthly expenses, but it doesn’t save you money or lower your drug costs.

Who is Likely to Benefit

You’re most likely to benefit from participating in the Medicare Prescription Payment Plan if you have high drug costs earlier in the calendar year. Although you can start participating in this payment option at any time in the year, starting earlier in the year (before September), gives you more months to spread out your drug costs. Go to Medicare.gov to answer a few questions and find out if you’re likely to benefit from this payment option.

This payment option may NOT be the best choice for you if:

  • Your yearly drug costs are low.
  • Your drug costs are the same each month.
  • You’re considering signing up for the payment option late in the calendar year (after September).
  • You don’t want to change how you pay for your drugs.
  • You get or are eligible for Extra Help from Medicare.
  • You get or are eligible for a Medicare Savings Program.
  • You get help paying for your drugs from other organizations, like a State Pharmaceutical Assistance Program (SPAP), a coupon program, or other health coverage.

How is My Monthly Bill Calculated

View sample calculations.

What Happens if I Don’t Pay My Bill?

You will receive a reminder from Paramount if you miss a payment. You are required to pay the amount you owe, but you will not pay any interest or fees, even if your payment is late. You can choose to pay that amount all at once or be billed monthly.

If you do not pay your bill, you will be removed from the Medicare Prescription Payment Plan. If you are removed from the Medicare Prescription Payment Plan, you will still be enrolled in your Medicare health or drug plan.

Always pay your Paramount plan monthly premium first (if you have one), so you don’t lose your drug coverage.

If Paramount receives an unmarked payment from you and we cannot determine if it is for your plan premium or Medicare Prescription Payment Plan balance, we will always apply the payment to your premium first.

Call CVS Customer Service toll free at 1-855-749-0851 (TTY: 711) if you think we made a mistake with your Medicare Prescription Payment Plan bill. If you think we made a mistake, you have the right to follow the grievance process found in your Member Handbook or Evidence of Coverage.

How Do I Sign Up for the Medicare Prescription Payment Plan?

Visit https://www.caremark.com/mppp or call CVS Customer Service toll free at 1-855-749-0851 (TTY:711).

During 2025: Starting Jan. 1, 2025, you can contact us to start participating in the Medicare Prescription Payment Plan anytime during the calendar year.

Remember, this payment option may not be the best choice for you if you sign up late in the calendar year (after September). This is because as new out-of-pocket drug costs are added to your monthly payment, there are fewer months left in the year to spread out your payments.

Filing Complaints and Grievances

If you have concerns about your Medicare Prescription Payment Plan, you can file a complaint (also known as a grievance). Filing a complaint ensures that your concerns are heard and addressed, helping to improve the quality of care and services you receive under your Medicare Prescription Payment Plan.

Types of Complaints

You can file a complaint about various issues, including:

  • Customer Service: Problems with how you were treated or the service you received.
  • Access to Specialists: Difficulty finding specialists within your plan.
  • Information from Paramount: Receiving unwanted materials or notices that don’t comply with Medicare rules.
  • Drug Errors: Issues like receiving the wrong medication or drugs that interact negatively.

Filing a Complaint

  • Timing: You must file your complaint within 60 days of the date of the event that led to the complaint.
  • Methods
    • Phone: Call Paramount directly at 1-833-554-2335 (TTY: 711) to file a complaint.
    • Writing: Submit your complaint in writing to Paramount.
    • Online: Use the Medicare Complaint Form available on the Medicare website.

Response Time

Paramount must notify you of our decision no later than 30 days after receiving your complaint.
If your complaint is about Paramount’s refusal to make a fast coverage determination or redetermination and you have not received the drug, we must respond within 24 hours.

Additional Help

If you need assistance with filing a complaint, you can contact your State Health Insurance Assistance Program (SHIP) for free, personalized help.

Election Requests

If you pay for your medication at the pharmacy because you believe that any delay in filling the prescription(s) due to the 24 hours timeframe required to process your Medicare Prescription Plan Payment request to opt in in may seriously jeopardize your life, health, or ability to regain maximum function, you can contact CVS Customer Service to request a retroactive enrollment.

You must request retroactive election within 72 hours of the date and time the urgent claim(s) occurred at the pharmacy.

Change In Health Plans

The program also accommodates mid-year plan election changes, allowing you to switch plans if necessary while maintaining your participation in the payment plan.

How do I leave the Medicare Prescription Payment Plan?

You can leave the Medicare Prescription Payment Plan at any time by contacting CVS Customer Service. Leaving won’t affect your Medicare drug coverage and other Medicare benefits. If you still owe a balance, you’re required to pay the amount you owe, even though you’re no longer participating in this payment option.

You can choose to pay your balance all at once or be billed monthly. You’ll then pay the pharmacy directly for new out-of-pocket drug costs after you leave the Medicare Prescription Payment Plan.

If you leave your current plan, change to a new Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage Plan with drug coverage), your participation in the Medicare Prescription Payment Plan will end. Contact your new plan if you’d like to participate in the Medicare Prescription Payment Plan again.

What Programs Can Help Lower My Prescription Drug Costs?

If you have limited income and resources, find out if you’re eligible for one of these programs:

  • Extra Help: A Medicare program that helps pay your Medicare drug costs. Visit the Social Security website to find out if you qualify and apply. You can also apply with your State Medical Assistance (Medicaid) office. Visit Medicare.gov/ExtraHelp to learn more.
  • Medicare Savings Programs: State-run programs that might help pay some or all of your Medicare premiums, deductibles, copayments, and coinsurance. Visit Medicare.gov's Medicare Savings Program page to learn more.
  • State Pharmaceutical Assistance Programs (SPAPs): Programs that might include coverage for your Medicare drug plan premiums and/or cost sharing. SPAP contributions may count toward your Medicare drug coverage out-of-pocket limit. Visit go.medicare.gov/spap to learn more.
  • Manufacturer Pharmaceutical Assistance Programs (sometimes called Patient Assistance Programs (PAPs)): Programs from drug manufacturers to help lower drugs costs for people with Medicare. Visit go.medicare.gov/pap to learn more.

Many people qualify for savings and don’t realize it. Visit Medicare.gov's Cost page help or contact your local Social Security office to learn more. Find your local Social Security office online.

What is the Medicare Low Income Subsidy (LIS)?

The Medicare Low-Income Subsidy (LIS) program, also known as “Extra Help,” is a federal initiative designed to assist Medicare beneficiaries with limited income and resources in paying for prescription drugs. This program helps cover costs such as monthly premiums, annual deductibles, and prescription co-payments associated with Medicare Part D.

Starting Jan. 1, 2024, the Inflation Reduction Act has expanded eligibility for the full LIS benefit to individuals with incomes up to 150% of the federal poverty level (FPL), who meet the necessary resource requirements. Previously, full benefits were only available to those with incomes up to 135% of the FPL, with partial subsidies for those up to 150%. This expansion aims to increase access to affordable prescription drugs for more individuals.

How to Apply and Enroll in the LIS Program

To apply for the LIS program, you can:

  1. Apply Online: Visit the Social Security Administration (SSA) website and complete the application form.
  2. Apply by Phone: Call the SSA at 1-800-772-1213 (TTY1-800-325-0778) to apply over the phone.
  3. Apply in Person: Visit your local Social Security office to request and submit an application.

After submitting your application, the SSA will review your financial situation and notify you of your eligibility. If approved, you will receive assistance with your Medicare Part D costs.

Advantages of LIS Enrollment

For those who qualify, enrolling in the LIS program is often more advantageous than participating in the Medicare Prescription Payment Plan. The LIS program provides more comprehensive financial assistance, reducing out-of-pocket costs for prescription drugs significantly. Additionally, it offers a Special Enrollment Period (SEP) to switch plans if needed and eliminates any Part D late enrollment penalties.

Where Can I Get More Information on the Medicare Prescription Payment Plan?

Visit Medicare.gov/prescription-payment-plan or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users can call 1-877-486-2048.

CVS Customer Service representatives can assist you with any Medicare Prescription Payment Plan questions. Representatives are available by calling toll free at 1-855-749-0851 (TTY: 711)  24 hours a day, 7 days a week.

Back to top

Medicare Part D Drug Transition Policy

New members in our health plan may be taking drugs that are not on our formulary (list of drugs) or that are subject to certain restrictions, such as prior authorization, quantity limits or step therapy. Current members may also be affected by changes in our formulary from one year to the next. If your drug is not on the Drug List or is restricted, here are things you can do:

  • You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). This will give you and your provider time to change to another drug or to file a request to have the drug covered.
  • You can change to another drug.
  • You can request an exception and ask the plan to cover the drug or remove restrictions from the drug.

You may be able to get a temporary supply.

Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.

To be eligible for a temporary supply, you must meet the two requirements below:

  1. The change to your drug coverage must be one of the following types of changes:
    1. The drug you have been taking is no longer on the plan's Drug List.
    2. or -- the drug you have been taking is now restricted in some way.
    3. Or - Part D drugs previously approved for coverage under an exception once the exception expires
  2. You must be in one of the situations described below:
    1. For those members who are new or who were in the plan last year:
      1. We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you were new and during the first 90 days of the calendar year if you were in the plan last year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. The prescription must be filled at a network pharmacy.  (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
    2. For those members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility and need a supply right away:
      1. We will cover one 31-day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above temporary supply situation.
    3. For those members who have been in the plan for more than 90 days and experience a level of care change (from one treatment setting to another):
      1. We will provide up to a one-month supply of a Non-Formulary Drug and/or a drug that may be restricted in some way, or less if your prescription is written for fewer days.
    4. Other times when we will cover a temporary 31-day transition supply (or less, if you have a prescription written for fewer days) include:
      1. When you enter a long-term care facility
      2. When you leave a long-term care facility
      3. When you are discharged from a hospital
      4. When you leave a skilled nursing facility

The plan will send you a letter within three business days of your filling a temporary transition supply, notifying you that this was a temporary supply and explaining your options.

Our transition supply will not cover drugs that Medicare does not allow Part D plans to cover, such as drugs used for erectile dysfunction or drugs for weight loss.
For more information regarding our Medicare Part D Transition Process please call our Member Services team at 1-833-554-2335 (TTY: 711 for hearing impaired).  From April 1 to Sept. 30, representatives are available Monday – Friday, 8 a.m. – 8 p.m. (except Memorial Day, Independence Day and Labor Day). From Oct. 1 to March 31, representatives are available seven days a week, 8 a.m. – 8 p.m. (except Thanksgiving and Christmas).

You and/or your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the rule. For example, you can ask the plan to cover a drug even though it is not on the plan's Drug List. Or you can ask the plan to make an exception and cover the drug without restrictions. If you and your provider want to ask for an exception, Chapter 9, Section 6.4 of the Evidence of Coverage tells what to do. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly.

Back to top

Quality Assurance

What is quality assurance?

Our quality assurance team ensures that – together with you and your doctor – we make the best healthcare decisions for you and your health needs. Part of that includes making sure you have access to the most appropriate services and medications provided by our health plan.

When it comes to Medicare Part D, our team carefully follows processes that review your prescriptions for your safety and good health.

Concurrent Drug Utilization Review

When a prescription is being filled at the pharmacy, it is reviewed for safety issues including:

  • Medication errors
  • Drug dosage (dose) and therapy duration (length of treatment) errors
  • Duplicate drugs – taking two drugs to treat the same medical condition when only one is necessary
  • Drug allergies
  • Harmful interactions between the drugs you are taking
  • Drugs that are not appropriate for your age or gender

Retrospective Drug Utilization Review

Retrospective Drug Utilization Review occurs after a prescription is filled. This process:

  • Reviews members’ drug histories
  • Identifies opportunities to improve quality of care by uncovering inappropriate or medically unnecessary medications

When it comes to Medicare Part D, our team carefully follows processes that review your prescriptions for your safety and good health.

Back to top

Medicare Part D Utilization Management

What is drug utilization management?

Our drug utilization management team wants to make sure that you are taking the right drug for the right length of time to best treat your medical condition. They use special systems that help prevent over- and under-utilization of prescribed medications. By carefully reviewing the medications that our members take, we can help improve health and, as appropriate, reduce medication costs. Tools we use to accomplish this include:

Prior Authorizations

For some drugs, you or your provider may need to get an approval from Paramount before the drug is covered. This is called prior authorization. Sometimes requiring approval in advance helps guide appropriate use of certain drugs. If you or your prescriber don’t submit a prior authorization, your drug may not be covered by your health plan.

Quantity Limits

For your safety, we may limit the amount of certain drugs that you can get each time you fill your prescription. For example, if it’s normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill a day.

Step Therapy

Based on best practices, we may require you to try certain drugs to treat your medical condition before we will cover a different drug for the same condition. For example, if Drug A and Drug B both treat your medical condition, the plan may not cover Drug B unless you try Drug A first. However, if Drug A does not work for you, the plan will then cover Drug B.

Generic Drugs

Usually, a generic drug works the same as a brand name drug and costs less. In most cases, when a generic version of a brand name drug is available, our network pharmacies will dispense the generic version. We typically will not cover the brand name drug when a generic is available. However, if your doctor requests the brand then we may cover it in certain instances.

Note: Your share of the cost may be greater for the brand name drug than for the generic drug. 

Back to top

Prescription Mail-order Services

Save on the medications you take regularly, such as high blood pressure or diabetes medicine, with 90-day refills from CVS Caremark Mail Service Pharmacy. It’s an easy way to make sure you have the medication you need, when you need it – making refilling these prescriptions one less thing to worry about.

Call CVS toll free at 855-749-0851 to set up your mail order account.

CVS will need to know your healthcare provider’s name and phone number, the name and strength of the medication, any allergies, and your payment information. CVS will contact your healthcare provider to obtain a new 90-day prescription for your medication.

Once your prescription is received from your provider, CVS will call you to confirm order details and begin the shipment process. New prescriptions will be mailed to you within 10 to 14 days after CVS receives your prescription.

Back to top

Medication Therapy Management

Help for Your Prescription Medications

The Paramount Elite Medication Therapy Management (MTM) Program is all about you and your health. The MTM Program helps you get the most out of your medications by:

  • Preventing or reducing drug-related risks
  • Supporting good lifestyle habits
  • Providing information for safe medication disposal options

FAQ

Who qualifies for the MTM Program?
You will be enrolled in the Paramount Elite MTM Program if you meet one of the following:

  • Meet the following criteria:
    • You have three or more of these conditions:
      • Alzheimer’s disease
      • Bone disease – arthritis (osteoarthritis, osteoporosis, rheumatoid arthritis)
      • Chronic congestive heart failure
      • Diabetes
      • Dyslipidemia
      • End-stage renal disease
      • HIV/AIDS
      • Hypertension
      • Mental health (depression, schizophrenia, bipolar disorder, chronic/disabling mental health conditions)
      • Respiratory disease (asthma, COPD, chronic lung disorders)
    • You take eight or more routine medications covered by your plan.
    • You are likely to spend more than $1,623 in Part D prescription drug costs in 2025.

    OR

  • You are identified as an At-Risk Beneficiary (ARB) under our Drug Management Program.

Your participation in the MTM Program is voluntary and does not affect your coverage. This is not a plan benefit and is open only to those who qualify. There is no extra cost to you for the MTM Program.

How will I know if I qualify for the MTM Program?
If you qualify, we will mail you a letter. You may also receive a call to set up your one-on-one medication review.

What services are included in the MTM Program?
In the MTM Program, you will receive the following services from a health care provider:

  • Comprehensive medication review
  • Targeted medication review

What is a comprehensive medication review?
The comprehensive medication review is completed with a health care provider in person or over the phone. This review is a discussion that includes all your medications:

  • Prescriptions
  • Over-the-counter (OTC)
  • Herbal therapies
  • Dietary supplements

This review usually takes 20 minutes or less to complete. During the review, you may ask any questions about your medications or health conditions. The health care provider may offer ways to help you manage your health and get the most out of your medications. If more information is needed, the health care provider may contact your prescriber.

After your review, you will receive a summary of what was discussed. The summary will include the following:

  • Recommended To-Do List. Your to-do list may include suggestions for you and your prescriber to discuss during your next visit.
  • Medication List. This is a list of all the medications discussed during your review. You can keep this list and share it with your prescribers and/or caregivers.

Who will contact me about completing the review?
You may receive a call from a pharmacy where you recently filled one or more of your prescriptions. You can choose to complete the review in person or over the phone.

A health care provider may also call you to complete your review over the phone. When they call, you can schedule your review at a time that is best for you.

  • Trusted MTM Program partners: You may receive a call from the CVS Caremark Pharmacist Review Team or the Outcomes Patient Engagement Team to complete this service.

What is a targeted medication review?
The targeted medication review is completed by a health care provider who reviews your medications at least once every three months. With this review, we mail, fax, or call your prescriber with suggestions about prescription drugs that may be safer or work better for you. As always, your prescriber will decide whether to consider our suggestions. Your prescription drugs will not change unless you and your prescriber decide to change them. We may also contact you by mail or phone with suggestions about your medications.

Why is this review important?
Different prescribers may write prescriptions for you without knowing all the medications you take. For that reason, the MTM Program health care provider will:

  • Review all your medications
  • Discuss how your medications may affect each other
  • Identify any side effects from your medications
  • Help you reduce your prescription drug costs

How do I benefit from talking with a health care provider?
By completing the medication review with a health care provider, you will:

  • Understand how to safely take your medications
  • Get answers to any questions you may have about your medications or health conditions
  • Review ways to help you save money on your drug costs
  • Receive a Recommended To-Do List and Medication List for your records and to share with your prescribers and/or caregivers

How can I get more information about the MTM Program?
Please contact us if you would like more information about the Paramount Elite MTM Program or if you do not want to participate. Our number is 833-554-2335, a Member Services representative is available Monday – Friday, 8 a.m. – 8 p.m. Note: From October 1 through March 31, we are available 8 a.m. – 8 p.m., seven days a week. If you use TTY telephone equipment, call us at 711.

How do I safely dispose of medications I don’t need?
The Paramount Elite MTM Program provides you with information about safe medication disposal. Medications that are safe for you may not be safe for someone else. Unneeded medications should be disposed of as soon as possible. You can discard your unneeded medications through a local safe disposal program or at home for some medications.

  • Locating a community safe drug disposal site A drug take back site is the best way to safely dispose of medications.
    • Find drug take back sites near you by entering your location.
    • Some pharmacies and police stations offer on-site drop-off boxes, mail-back programs, and other ways for safe disposal. Call your pharmacy or local police department (non-emergency number) for disposal options near you.
  • Mailing medications to accepting drug disposal sites
    • Medications may be mailed to authorized sites using approved packages. Information on mail-back sites can be found at www.deatakeback.com.
  • Safe at-home medication disposal
  • Steps for medication disposal in the trash:
    • Remove medication labels to protect your personal information
    • Mix medications with undesirable substances, such as dirt or used coffee grounds
    • Place mixture in a sealed container, such as an empty margarine tub

Back to top

Drug Management Program

Paramount is committed to ensuring the safe use of all prescription medications. The Paramount Drug Management Program (DMP) focuses on the safe use of opioids, benzodiazepines and other frequently abused drugs. This program helps coordinate care for Medicare members who get opioid prescriptions from multiple doctors or pharmacies.

Throughout the year, Paramount will review opioid medication usage and identify members who would benefit from our DMP. If we find possible unsafe usage or overuse of prescription opioids, benzodiazepines and other frequently abused drugs we typically contact your prescriber to better coordinate care. Based on these discussions and the outcome of this review, we may add certain limits on your coverage for these types of drugs. For example, members may be required to get these medications from certain doctors or pharmacies. You will be notified in writing if this occurs.

If you think that we’ve made a mistake or would like to appeal this determination, you, your doctor or authorized representative can file an appeal. You should review the information contained in your notification letter for more information about how to request an appeal or visit our Coverage Redetermination and Appeal section.

For more information about the DMP or how to submit an appeal, call Member Services at 1-833-554-2335 (TTY: 711 for hearing impaired).

Back to top

Part D Forms

Medicare Part D Authorization Request Forms

Medicare Part D Electronic Submission

Back to top

Other Plan Information

Appointment of Representative

You Can Ask Someone to Act on Your Behalf

If you would like to name another person to act as your representative so that this person can contact Paramount and CVS Caremark and make requests for you, please call Member Services and ask for the Appointment of Representative form (called the “AOR” form). The AOR form gives this person (your representative) the authority to contact Paramount and CVS Caremark and act on your behalf for one (1) year after the date of the signatures on your form. You must enter all of your information and your representative’s information onto the AOR form and both of you must sign it.

If you want to appoint a representative but you don’t want to use the AOR form, you may write or type your own appointment of representative letter, however, your letter must contain the same information that is required on the AOR form.  You may appoint any person over the age of 18 years to be your representative for this purpose.  Also, please know that you do not need to be related to person whom you are appointing as your representative.

Once you have the form completely filled out and signed, or you have written your own form letter, and both you and your representative have signed it, you must send it to Paramount Member Services either by mail, fax, email (please ask us how to send it securely), or in person at our Beaver Creek location in Maumee.  Your representative will not be able to make any requests with Paramount on your behalf until Paramount receives and accepts your request to appoint this person as your representative.

After Paramount receives and accepts your AOR form (or your own written form letter), then your representative may contact Paramount or CVS Caremark and make requests for you (such as an initial determination, appeal, or complaint) for a period of one (1) year after your form (or letter) was signed.

PLEASE NOTE: Your representative will be acting on your behalf, so your representative will receive all of the updates and written notices, including decision notices, that are related to any request that was filed for you by your representative. You may request a copy of any of these notices at any time by calling Member Services.

You do not need to appoint a representative to act on your behalf, unless you want to. 

Back to top

Getting Care During a Disaster

Per your Evidence of Coverage, if the Governor of your state, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in your geographic area, you are still entitled to care from your plan. If you cannot use a network provider during a disaster, your plan will allow you to obtain care from out-of-network providers at in-network cost sharing. If you cannot use a network pharmacy during a disaster, you may be able to fill your prescription drugs at an out-of-network pharmacy.

Back to top

Best Available Evidence

In certain cases, the Centers for Medicare and Medicaid Services (CMS) may give you incorrect information on your low-income subsidy status. The Best Available Evidence policy allows us to use “best available evidence” in these cases to help determine your correct low-income subsidy status.

If you believe you have been given incorrect information on your low-income subsidy status, please send us one or more of the following:

  • A copy of your Medicaid card that includes your name and an eligibility date during a month after June of the previous calendar year.
  • A copy of a state document that confirms active Medicaid status during a month after June of the previous calendar year.
  • A print out from the State electronic enrollment file showing Medicaid status during a month after June of the previous calendar year.
  • A screen print from the State’s Medicaid systems showing Medicaid status during a month after June of the previous calendar year.
  • Other documentation provided by the State showing Medicaid status during a month after June of the previous calendar year.
  • For individuals who are not deemed eligible, but who apply and are found LIS eligible, a copy of the SSA award letter.

If you are institutionalized, please send us one or more of the following:

  • A remittance from the facility showing Medicaid payment for a full calendar month during a month after June of the previous calendar year.
  • A copy of a state document that confirms Medicaid payment on your behalf to the facility for a full calendar month after June of the previous calendar year.
  • A screen print from the State’s Medicaid systems showing your institutional status based on at least a full calendar month stay for Medicaid payment purposes during a month after June of the previous calendar year.

For more information on the Best Available Evidence policy, please visit the CMS webpage.

Back to top

Disenrollment Information

Back to top

Payment Information

We make paying your premium easy. There are four ways you can pay your monthly premium directly to Paramount.

  • Receive a bill in the mail each month. Then send in your payment.
  • Pay by automatic bank draft.  If you are interested in this payment option, please complete the bank draft form and send it to us.
  • Have your premium automatically deducted from your monthly Social Security check (SSA) or Railroad Retirement Board (RRB) benefit check.
  • Note: Once the Social Security Administration (SSA) or Railroad Retirement Board (RRB) approves the deduction, it may take two or more months to begin.
  • Manage your account online.
    • Pay Now allows you to make a one-time payment.
    • Pay My Bill allows you to enroll in our paperless invoice and payment system.
    • After you receive your first monthly invoice, you can also sign up for paperless billing at Pay My Bill.
    • Manage Your Account Online

If you need assistance, call Member Services at 567-585-9888.

Back to top

Indiana Counties: Adams, Allen, Dearborn, DeKalb, Franklin, Ohio, Noble, Switzerland

Kentucky Counties: Boone, Campbell, Kenton

Michigan Counties: Branch, Hillsdale, Lenawee, Monroe and Washtenaw

Ohio Counties: Adams, Allen, Ashland, Auglaize, Brown, Butler, Champaign, Clark, Clermont, Clinton, Crawford, Cuyahoga, Darke, Defiance, Erie, Fayette, Fulton, Geauga, Greene, Hamilton, Hardin, Henry, Highland, Huron, Lake, Lorain, Lucas, Madison, Medina, Mercer, Miami, Montgomery, Ottawa, Paulding, Portage, Preble, Putnam, Sandusky, Seneca, Shelby, Summit, Van Wert, Warren, Wayne, Williams, Wood and Wyandot  

Page last updated on 6/19/2025
Y0121_W2278_2025_M