Coverage Determination


Medicare Part D Coverage Determination Form (for use by Enrollees and Providers)

Revised Standardized Pharmacy Notice

Transition Process

If one of your drugs is not covered in the way you would like it to be covered, you have the right to ask for a “coverage determination”. A coverage determination is when we make a decision about whether a drug is covered by the plan and the amount, if any, you are required to pay for the prescription.

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.
You cannot ask for coverage of any “excluded drugs” or other non-Part D drugs which Medicare does not cover. (For more information about excluded drugs, see Chapter 5 of the Evidence of Coverage.)
Here are examples of exceptions that you or your doctor or other prescriber can ask us to make:

  1. Covering a Part D drug for you that is not on our plan’s List of Covered Drugs (Formulary). Asking for coverage of a drug that is not on the Drug List is sometimes called asking for a “formulary exception.”

  2. Removing a restriction on the plan’s coverage for a covered drug. There are extra rules or restrictions that apply to certain drugs on the plan’s List of Covered Drugs such as quantity limits. Asking for removal of a restriction on coverage for a drug is sometimes called asking for a “formulary exception.”
    • If our plan agrees to make an exception and waive a restriction for you, you can ask for an exception to the co-payment or coinsurance amount we require you to pay for the drug.
  3. Changing coverage of a drug to a lower cost-sharing tier. Every drug on the plan’s Drug List is in one of 5 cost-sharing tiers. In general, the lower the cost-sharing tier number, the less you will pay as your share of the cost of the drug. Asking to pay a lower preferred price for a covered non-preferred drug is sometimes called asking for a “tiering exception.”
    • If your drug is in Tier 4, Tier 3, or Tier 2, you may ask us for a tiering exception. If approved, this would lower your share of the cost for the drug.
    • You cannot ask us to change the cost-sharing tier for any drug in Tier 5 which is our Specialty Drug tier.
  4. Asking the plan to pay our share of the cost of your covered prescription. In certain situations you may be required to pay the full cost of your medication or may have paid more than you expected to under the coverage rules of your plan. In either case you may ask our plan to pay you back. Asking for payment is called a coverage determination about payment or “request for reimbursement”.

How to ask for a coverage decision, including an exception

You may ask our plan to make a coverage decision about the drug(s) or payment you need. If your health requires a quick response, you must ask us to make a “fast decision.” You cannot ask for a fast decision if you are asking us to pay you back for a drug you already bought.

    What to do

  • Request the type of coverage decision you want. You, your representative, or your doctor (or other prescriber) can request a coverage determination by calling, emailing, writing, or faxing our plan at the numbers below. The forms below may be used for formulary and/or tiering exceptions (as described above).

Telephone: 330-363-7407 or toll free 1-800-577-5084 or, for TTY users, 330-363-7460 or 1-800-617-7446, Monday through Friday, 8:00 a.m. to 8:00 p.m. (October 1st – February 14th, we are available 7 days a week, 8:00 a.m. to 8:00 p.m.)

Email: [email protected]

Fax: 330-580-6764

Mail: P.O. Box 6905, Canton, Ohio 44706

  • When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard decision means we will give you an answer within 72 hours after we receive your doctor’s statement. A fast decision means we will answer within 24 hours.

  • To get a fast decision, you must meet two requirements:
    • You can get a fast decision only if you are asking for a drug you have not yet received. (You cannot get a fast decision if you are asking us to pay you back for a drug you are already bought.)
    • You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.
  • If your doctor or other prescriber tells us that your health requires a “fast decision,” we will automatically agree to give you a fast decision.

  • If you ask for a fast decision on your own (without your doctor’s or other prescriber’s support), our plan will decide whether your health requires that we give you a fast decision.
    • If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter that says so (and we will use the standard deadlines instead).
    • This letter will tell you that if your doctor or other prescriber asks for the fast decision, we will automatically give a fast decision.
    • The letter will also tell how you can file a complaint about our decision to give you a standard decision instead of the fast decision you requested. It tells how to file a “fast” complaint, which means you would get our answer to your complaint within 24 hours. (The process for making a complaint is different from the process for coverage decisions and appeals).

Our plan can say yes or no to your request

If we approve your request we will provide the coverage we have agreed to within the appropriate time frame. We will also notify you in writing of our decision.

If we deny your request, we will send you a written notice that explains why we said no. If we say no to your coverage request, you have the right to request an appeal. Requesting an appeal means asking us to reconsider – and possibly change – the decision we made.

Appointment of Representative Form

If you choose a friend, relative, provider, or other person to be your representative, please complete and return this form. It must be signed by you and the representative acting on your behalf. You must give us a copy of the signed form.

Last updated: 10/1/2015