Coverage Determination

A coverage determination is any decision made by the Part D plan sponsor regarding:

1. Receipt of, or payment for, a prescription drug that an enrollee believes may be covered;

2. A tiering or formulary exception request (for more information about exceptions, click on the exceptions link in the side section);

3. The amount that the plan sponsor requires an enrollee to pay for a Part D prescription drug and the enrollee disagrees with the plan sponsor;

4. A limit on the quantity (or dose) of a requested drug and the enrollee disagrees with the requirement or dosage limitation;

5. A requirement that an enrollee try another drug before the plan sponsor will pay for the requested drug and the enrollee disagrees with the requirement; and

6. A decision whether an enrollee has, or has not, satisfied a prior authorization or other utilization management requirement.

An enrollee, an enrollee’s physician, or an enrollee’s appointed representative may request a standard or expedited coverage determination by filing a request with the plan sponsor.

Initial decisions on Part D Drugs are called “coverage determinations”.  With this decision, we explain if we will provide the Part D drug you are requesting, or if we will pay for the Part D drug service you just received.

For more information you can call our Customer Service Department at 1-888-767-7717 Monday thru Friday from 8:00 am to 8:00 pm. TTY /TDD users should call 1-877-672-4242.

For a Medicare Prescription Drug Coverage Request Form, click on the following link which will redirect you to the CMS website:

https://www.cms.gov/MedPrescriptDrugApplGriev/Download/ModelCoverageDeterminationRequestForm.pdf

We will provide a decision notice for benefit requests that do not involve exceptions, within 24 hours after receiving an expedited request or 72 hours after receiving a standard request.