Coverage Determinations, Appeals, and Grievances
If you want to request coverage of a drug not on our formulary, a waiver of our utilization management requirements, or a decrease in your cost-sharing amount, you can request an exception. Learn how to ask for an exception and the next steps you or your provider can take.
What is a Coverage Determination?
Any determination to provide or pay for a Part D drug that you believe may be covered by the plan (including a decision not to pay because the drug is not on the plan’s formulary, because the drug is determined not to be medically necessary, because the drug is furnished by an out of network pharmacy or because the Part D plan sponsor determines that the drug is otherwise excluded under section 1862(a) of the Act if applied to Medicare Part D).
- Prior Authorization or other Utilization Management Request: Coverage determination decisions related to whether you have, or have not, satisfied a prior authorization or other utilization management requirement (such as step therapy or quantity limits) for a Part D drug.
- Exception Requests: An exception is a type of coverage determination decision involving a Part D drug. You, your doctor, or other prescriber may ask us to make an exception to our Part D coverage rules in a number of situations including:
- Asking us to cover your Part D drug even if it is not on our formulary. Excluded drugs cannot be covered by a Part D plan unless coverage is through an enhanced plan that covers those excluded drugs.
- Asking us to waive coverage restrictions or limits on your Part D drug. For example, for certain Part D drugs, we limit the amount of the drug that we will cover. If your Part D drug has a quantity limit, you may ask us to waive the limit and cover more.
- Tier Exception Requests: Asking us to pay a lower price for a covered Part D drug on a higher cost sharing tier through the tiering exception process.
- If our drug list contains alternative drug(s) for treating your medical condition that are in a lower cost-sharing tier than your drug, you can ask us to cover your drug at the cost sharing amount that applies to the alternative drug. This could lower your share of the cost for the drug.
- If we approve your request for a tiering exception and there is more than one lower cost-sharing tier with alternative drugs you can’t take, you will usually pay the lowest amount.
- You cannot ask us to change the cost sharing tier of any drug in the Specialty tier (Tier 5).
- If we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage on a lower cost-sharing tier for the drug.
- Reimbursement Requests: Coverage determination decisions concerning reimbursement for Part D prescription drugs that you have already purchased.
Who Can Request a Coverage Determination?
- Your authorized representative
- Your prescribing physician
- You can appoint a representative to act on your behalf for filing a coverage determination by providing us with a completed Appointment of Representative Form or visit the CMS Medicare website.
How to Request a Coverage Determination
Submit an Online Coverage Determination request: Request for Medicare Prescription Coverage Determination
- Call us:
For HMO Members: (844) 918-0114
For PPO Members: (844) 915-0234
- Send us a fax: (888) 904-1139
- Send us your request form in writing:
P.O. Box 1285
Maryland Heights, MO 63043
What is the Coverage Determination process?
After receipt of a request for coverage determination, we will review it and notify you or your authorized representative, and your prescribing physician (as appropriate) of our decision regarding your request for the coverage determination as expeditiously as your health condition requires.
- Standard requests - we will advise you of our decision no later than 72 hours from the receipt of the request, or, for an exception request, no later than 72 hours from receipt of the physician's supporting statement.
- Fast requests (or expedited requests) - we will advise you of our decision no later than 24 hours from the receipt of the request, or, for an exception request, no later than 24 hours from receipt of the physician's supporting statement.
- Reimbursement requests – we will advise you of our decision no later than 14 days from receipt of the request.
Coverage Determination Approvals
If we decide the coverage determination fully in your favor and approve coverage, we will:
- Attempt to contact you by phone
- Send written approval notification to you and your prescribing physician
- Authorize the drug, which will allow the pharmacy to process your prescription
Coverage Determination Denials
For denials related to drug coverage, in whole or in part, we will send written notice of the determination and attempt to provide verbal notification. Your prescribing physician will also receive written notification if they provided a supporting statement. The denial notice will state the specific reason for the denial and contain all applicable Medicare appeals language.
If we fail to make a coverage determination within the specified timeframe, it constitutes an adverse coverage determination. We will then send the request to the Independent Review Entity (IRE) designated by CMS within 24 hours of the expiration of adjudication timeframe and the IRE will issue a determination. You will be notified in writing that your request was sent to the IRE.
An adverse coverage determination or denial constitutes any unfavorable decision made by or on behalf of the plan regarding coverage or payment for prescription drug benefits you believe you are entitled to receive. The following actions are considered adverse or denied coverage determinations for decisions not to provide or pay for a prescription drug which include:
- Not to pay because the drug is not on the plan's formulary,
- Not to pay because it has been determined that the drug is not medically necessary,
- Not to pay because the drug is furnished by an out of network pharmacy, or
- It is determined the drug is otherwise excluded under section 1862 (a) of the Social Security Act that you believe should be covered by the plan.
- The failure to provide a coverage determination in a timely manner when a delay would adversely affect your health.
If you disagree with a decision we have made, you have the right to appeal that decision. The first level of appeal for an adverse or denied coverage determination under Medicare Part D is called a redetermination request.
Appeals or Redeterminations
If you are unhappy with an unfavorable or denied coverage determination (the decision made on your initial request) you may file an appeal or redetermination. When you file a redetermination, you’re asking us to review the request again. Members appeal when they think the decision made was unfair or in error.
When you want us to reconsider an adverse coverage determination made regarding what prescription drugs are covered or what we will pay, you can request an appeal within 60 days of the initial denial. This includes a delay in providing or approving drug coverage (when the delay will affect your health), or on any amounts you must pay for drug coverage.
Who can request a Redetermination?
You or your authorized representative, or your prescribing physician can request a redetermination. You can appoint a representative to act on your behalf for filing an appeal by providing us with a completed Appointment of Representative Form or visit the CMS Medicare website at: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS012207
How to request a Redetermination
- Call us at: (844)-918-0114 (HMO), (844) 915-0234 (PPO)
- Fax us at: (888) 904-1139
- Mail to: P.O. Box 1285 Maryland Heights, MO 63043
What is the Redetermination process?
When you request a standard appeal or redetermination, we will process your request within 7 calendar days of receipt of the request. If you or your prescriber believes that waiting 7 days could seriously harm your health, you can request a fast or expedited appeal and we will give you a decision within 72 hours. You cannot request an expedited appeal if you are asking us to pay you back or reimburse you for a drug already received.
For all appeals, we will review the request for redetermination and will provide you notice of our decision in writing (and process the change, if favorable) as expeditiously as your health condition requires.
- Attempt to contact you by phone (only for fast or expedited appeals)
- Send written notification to you and your prescribing physician
- If denied, the denial notice will state the specific reason for the denial and contain all applicable Medicare appeals language.
- If approved, authorize the drug, which will allow the pharmacy to process your prescription
If we fail to make a redetermination decision within the specified timeframe, it constitutes an adverse determination. We will then send the request to the Independent Review Entity (IRE) designated by CMS within 24 hours of the expiration of adjudication timeframe and the IRE will issue a determination. You will be notified in writing that your request was sent to the IRE.
If you disagree with the decision regarding your appeal or request for redetermination, you may file an appeal with an outside entity. For further information regarding appeals, refer to your Explanation of Coverage (EOC) or call Member Services at (844) 918-0114 for HMO Members or (844) 915-0234 for PPO Members: TTY: 711
Member Services is open From October 1 to March 31. You can call us 7 days a week from 8am to 8pm EST. From April 1 to September 30, you can call us Monday through Friday from 8am to 8pm EST.