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Coverage Decisions

What is a coverage determination?

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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.

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 permission to get coverage for a drug that is not normally on our List of Covered Drugs or to use the drug without certain limitations.

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
  • Waive a restriction on the plan’s coverage for a drug (such as limits on the amount of drug you can get)
  • Cover a drug and you believe that you meet any plan rules or restrictions (such as a prior authorization) should be waived for your request.
  • Pay for a prescription that you already bought. This is a coverage decision about payment. You can request that we reimburse you by submitting this form, along with your receipts.

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.

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 calendar 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.

  • The plan will give you an answer on a standard coverage decision within 72 hours.
  • Exception requests regarding reimbursement for your Part D drug you already paid for will be provided within 14 calendar days.
  • If your health requires a quick response, you may ask us to make a fast decision. The plan will usually respond within 24 hours.
  • 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 a Coverage Determination or Exception be filed?

You, your representative or your prescriber can request a coverage review by

  • Calling Member Services at 1-855-817-5785 (TTY 711) Monday through Friday from 8 a.m. to 8 p.m.
  • Faxing your request to 1-844-493-9213
  • Asking your physician to submit a request through CoverMyMeds®

H6229_19_109255_U CMS Accepted 06/28/2019 Page Last Updated on 10/04/2019