Determinations & Exceptions

What is an organization determination?

Organization determinations are also called “coverage decisions.” A coverage decision is an initial decision we make about your benefits and coverage or about the amount we will pay for your medical services, items, or drugs. We are making a coverage decision whenever we decide what is covered for you and how much we pay.

If you or your doctor are not sure if a service, item, or drug is covered by Medicare or Medi-Cal, either of you can ask for a coverage decision before the doctor gives the service, item, or drug.

What is a coverage determination?

A coverage determination is a decision made by our plan (not the pharmacy) about your prescription drug benefits. To ask for a coverage determination, fill out the Coverage Determination Form.

The decision includes:

  • If we cover the drug
  • If you've met all the requirements for getting the drug you've asked for
  • How much you'll have to pay for a drug
  • If we'll make exception to a plan rule when you've asked us to do so

What is an exception?

If a drug is not covered on our plan, you can ask the plan to make an exception. An exception is a type of coverage decision. If we turn down your request for an exception, you can appeal our decision, or ask us to review our decision. When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request.

When can I ask for a coverage determination or exception?

You can ask for coverage determination or
exception if you want us to:

  • Cover a Part D drug for you that’s not on our plan’s List of Covered Drugs
    • You may ask our plan for an exception if you or your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) believes you need a drug that isn’t on our drug plan’s List of Covered Drugs.
    • You may ask for an exception if your network pharmacy can’t fill a prescription as written.
  • Remove a restriction on the plan’s coverage
    for a covered drug
    • You may ask for an exception if you or your prescriber believe that a coverage rule (such as a prior authoization) should be waived for your request.
  • Change coverage of a drug to a lower cost-sharing tier (tier exception)
    • You may ask for an exception if you think you should pay less for a higher tier drug because you or your prescriber believe you can’t take any of the lower tier drugs for the same condition.
  • Request for payment
    • You may ask us to pay for a prescription that you already paid for. To appeal our decision to deny your request for coverage of (or payment for) a prescription drug, fill out the Redetermination Request form.

Who can ask for a coverage determination/exception?

You or your representative may request a coverage determination.
Your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) can request a coverage determination for you on your behalf.

Important things to know when asking for exceptions
Your doctor or other prescriber must give us a written statement that explains the medical reasons for asking for an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception.

Our plan can say "yes" or "no" to your request:
If we approve your request for an exception, our approval usually is good until the end of the plan year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.

If your health requires a quick response, you may ask us to make a fast decision. We have 24 hours to respond with a fast decision. For non-urgent requests, we have 72 hours to respond.

If we say "no" to your request for an exception, you can ask for a review of our decision by making an appeal for a reconsideration. Our health plan has 7 calendar days to respond. We will make our decision as fast as possible, but no later than 72 hours after receiving the request if the appeal is urgent.

Where can an exception be filed?

You, your representative or your prescriber can request an
exception or expedited (fast) exception by:

  • Calling Member Services at 1-888-817-5785 (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. Pacific time
  • Faxing your request to1-855-856-1724

Our plan has 72 hours (for a standard request) or 24 hours (for a fast request) from the date we get your request to let you know our decision.

H6229_17_30116_R CMS Approved 02/10/2017 Page Last Updated On 10/1/2018