Coverage Decisions

What is a coverage decision?

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.

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

Ask your physician to submit a request through CoverMyMeds® or Surescripts.

How long does it take to get a coverage decision?

After you ask and we get all of the information we need for medical services and items, we will notify you of our determination no later than 14 calendar days. If your request is for a Medicare Part B prescription drug, we will give you a decision no more than 72 hours after we receive your request. If we don't give you our decision within 14 calendar days (or 72 hours for a Medicare Part B prescription drug), you can appeal. Sometimes we need more time and we will send you a letter telling you that we need to take up to 14 more calendar days.

For Part D, we will provide you with a decision in 24 hours for urgent (fast) requests, and 72 hours for non-urgent requests. Sometimes we need more time and we may need to call your doctor for additional information. When that happens, it may take up to 14 days for you to receive a decision.

You can ask for a fast decision if you feel that waiting for a decision would be harmful to your health. Please note that you cannot get a fast coverage decision if you are asking us to pay you back for a drug you already bought.

For Part C, if you need a response faster because of your health, you should ask us to make an "expedited organization determination." If we approve the request, we will notify you of our decision within 72 hours. However, sometimes we need more time and we will send you a letter telling you that we need to take up to 14 more calendar days. To ask for an expedited organization determination please call Member Services at 1-855-817-5785 (TTY: 711) Monday through Friday from 8 a.m. to 8 p.m. The call is free.

Who can ask for a coverage determination / exception?

You or your representative may request a coverage determination.
Your doctor or other prescriber can request a coverage determination for you on your behalf.

If you want a friend, relative or other person to be your representative, call Member Services and ask for the "Appointment of Representative" form. You can also get the form on the Medicare website via the link below. The form will give the person permission to act for you. You must give us a copy of the signed form with your request.

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.

We will say Yes or No to your request for an exception:
If we say Yes to your request for an exception, the exception usually lasts until the end of the calendar year for most drugs. 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 we say No to your request for an exception, you can ask for a review of our decision by making an appeal.

Where can an organization determination request for Part B and Part C be filed?

You, your representative or your doctor can request an organization determination by:

• Calling Member Services at 1-855-817-5785 (TTY: 711) Monday through Friday from 8 a.m. to 8 p.m. The call is free.
• Faxing your request to 1-562-622-3066
• Mailing your request to
  MMP Utilization Management
  12900 Park Plaza Drive, Suite 150
  MS-7120
  Cerritos, CA 90703

Our plan has 72 hours (for a standard request) or 24 hours (for a fast request) from the date we get the required information to let you know our decision. We will give you an answer on reimbursing you for a Part D drug you already paid for within 14 calendar days.