Coverage Determinations involve decisions whether or not to provide or pay for a Part D drug
and what your cost-sharing is for the drug. Coverage determinations include “exceptions” i.e., you
may request an "exception" to our Formulary rules. For example, if you believe you need a drug that
is not on our Formulary (a “formulary exception”) or you believe you should get a drug at a lower cost
share (a “tiering exception”). All requests for exceptions must be supported by a statement by the
prescribing physician. Standard Coverage Determinations will be made within seventy-two (72) hours and
Fast Coverage determinations will be made within twenty-four (24) hours.
You, your appointed representative, or your provider may request a Coverage Determination or exception
by completing the Request for Medicare Part D Coverage Determination Form.
CALL 1-800-797-9791 (TTY/TDD 1-866-524-4174). Calls to this number are free.
FAX 1-866-308-6294 (for standard appeal); 1-866-308-6296 (for fast appeals).
WRITE P. O. Box 6106, Mail Stop CA 124-0197, Cypress, CA 90630-9948, Attn. Part D Appeal and Grievance Dept.
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An exception is a type of initial determination (also called a “coverage determination”)
involving a Part D drug. You or your doctor may ask us to make an exception to our Part D coverage
rules in a number of situations.
You may ask 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.
You may ask 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. See Section 2 (“Utilization Management”) to
learn more about our additional coverage restrictions or limits on certain drugs.”
You may ask us to provide a higher level of coverage for your Part D drug. If your Part D drug is
contained in our non-preferred brand tier, you may ask us to cover it at the cost-sharing amount
that applies to drugs in the preferred brand tier instead. This would lower the co-payment amount
you must pay for your Part D drug. Please note, if we grant your request to cover a Part D drug that
is not on our formulary, you may not ask us to provide a higher level of coverage for the drug.
Also, you may not ask us to provide a higher level of coverage for Part D drugs that are in the
Injectable and Specialty Drug tier.
Your doctor must submit a statement supporting your exception request. In order to help us make
a decision more quickly, the supporting medical information from your doctor should be sent to us with the
exception request.
If we approve your exception request, our approval is valid for the remainder of the Plan year, so long
as your doctor continues to prescribe the Part D drug for you and it continues to be safe for treating your
condition. If we deny your exception request, you may appeal our decision.
Note: If we approve your exception request for a Part D non-formulary drug, you cannot request
an exception to the co-payment or coinsurance amount we require you to pay for the drug.
You may call us at the phone number shown under Part D Coverage Determinations in Section
8 of your Evidence of Coverage to ask for any of these requests.
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