Coverage Determinations

Reasons to request a coverage determination

• If coverage was denied at the pharmacy for a drug you think we do cover
• If we notify you that coverage for a drug you take will be reduced or stopped
• If your drug requires a Prior Authorization
• If, based on your situation, you want to request an exception to a restriction or limit applied to a drug
• If a drug you believe you need is not covered on the formulary
• If you want to request coverage at an out-of-network pharmacy
• If you want to request coverage of a drug at a lower tier than the one assigned on the formulary
• If you want to request an exception to a plan rule

How to request a coverage determination

If you, your doctor or authorized representative would like to request a coverage determination, complete and submit an Electronic Beneficiary Coverage Determination form, or call us at the number on your Member ID card. You must submit your request no later than three years from the date of service.

To ensure we have all the necessary information, it’s best for your doctor to submit your request. If you choose to appoint a relative, friend, advocate, doctor or anyone else to act as your legal representative, you and your appointed person must complete and sign an Appointment of Representative form and file it with each request for a coverage determination. However, you are not required to hire an attorney or appoint a representative.

Response timing

For a standard coverage determination we will make a decision within 72 hours of receiving your request.

You can request an expedited coverage determination if you or your doctor believes that waiting 72 hours could seriously harm your health or your ability to function. If we grant your request, we will make a decision within 24 hours. This option applies only to drugs you have not yet received.

If your doctor asks for the expedited coverage determination, or provides a written statement, we will automatically make a decision within 24 hours. If you request the expedited determination, and your doctor does not provide a written statement, we will decide if your health situation requires an expedited determination. If we deny your request, you can have it expedited by getting a supporting statement from your doctor. Your physician may contact us directly regarding the status of your coverage determination.

For a coverage decision about payment for a drug you have already bought we must give you an answer within 14 calendar days after we receive your request.

If your request is approved

An approved request for Coverage Determination is usually called a formulary exception. This means that we are granting an exception to a rule established by your plan’s formulary. You will receive notice of approval, which will include the date that your exception will expire.

If your request is denied

If we deny your request entirely or in part, we will send you a written explanation. You have the right to appeal the decision by requesting a redetermination. Call Customer Care at the number on your Member ID card for more information.