Coverage Determination Process

What is a coverage determination?
The coverage determination is the starting point for dealing with requests to cover or pay for a Part D prescription drug that our Plan does not already cover.

If your doctor or pharmacist tells you that a certain prescription drug is not covered, you can ask us for a coverage determination. If we deny your request (this is sometimes called an “adverse coverage determination”), you can “appeal” our determination. Please click filing an Appeal for more information.

The following are examples of when you may want to ask us for a coverage determination. Most of these requests concern drugs that are not on our formulary, no longer covered or have some type of requirement or limitation attached. Some of these requests involve a coverage determination about payment.

Examples of Coverage Determination items include:

  • If you are not getting a prescription drug that you believe may be covered by us.
  • If you have received a Part D prescription drug you believe may be covered by us while you were a member, but we have refused to pay for the drug.
  • If we will not provide or pay for a Part D prescription drug that your doctor has prescribed for you because it is not on our list of covered drugs (called a “formulary”). You can request an exception to our formulary.
  • If you disagree with the amount that we require you to pay for a Part D prescription drug that your doctor has prescribed for you. You can request an exception to the co-payment we require. If you are being told that coverage for a Part D prescription drug that you have been getting will be reduced or stopped.
  • If there is a limit on the quantity (or dose) of the drug and you disagree with the requirement or dosage limitation.
  • If you are required to try another drug before we will pay for the drug you are requesting.
  • If you bought a drug at an out-of-network pharmacy and you want to request reimbursement. In certain circumstances, out-of-network purchases, including drugs provided to you in a doctor’s office, will be covered by the plan.
  • You ask us to pay for a drug you have already received.
  • You ask for an exception to our plan’s utilization management tools. This is another type of formulary exception.
  • You ask for a non-preferred Part D drug at the preferred cost-sharing level. This is a request for a tiering exception.

When we make a coverage determination, we are giving our interpretation of how Plan benefits apply to your specific situation. Refer to your Evidence of Coverage and any amendments you may receive that describe our Plan coverage. This booklet also lists exclusions (benefits that are not covered).

Who may ask for a coverage determination?
You, your doctor or your appointed representative can ask us for a coverage determination. Information about appointing a representative is discussed below. If you use a representative, a copy of the signed appointed representative form must be submitted for each appeal request and is valid for one year.

You also have the right to have an attorney ask for a coverage determination on your behalf. You can contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify.

To file a Coverage determination request, you must complete and submit the Beneficiary Coverage Determination Request Form to our Appeals Department at:

P.O. Box 52000, MC109, Phoenix, AZ 85072-2000.

If you prefer you may fax the form to (866) 884.9475. If you want to make either an expedited or oral request, call Customer Care, 24 hours a day, 7 days a week at 1-866-235-5660. TTY users should call 1-866-236-1069. Please refer to your Evidence of Coverage and any amendments you may receive that describe our plan coverage. This booklet also lists exclusions (benefits that are not covered). Please refer to Chapter 5, Section 5.1 of your Evidence of Coverage for information regarding the coverage determination process.

To review this information in your Evidence of Coverage, click on:

  • Select a Plan of this site's sidebar
  • Enter a State
  • Select a Plan
  • Scroll to the bottom of the page until you see click here to download your plan documents
  • Click on Evidence of Coverage

Click here to download the Beneficiary Coverage Determination form. It may save time if you have your doctor complete the form to ensure we have all the necessary information which will reduce the possibility of us having to contact your doctor for additional information. Click here to download the Physician Coverage Decision form.

Appointing a representative
If you want to name a relative, friend, advocate, doctor, or anyone else to act for you as your appointed representative, you and that person will need to complete and sign the SilverScript Insurance Appointment of Representative form. By completing this form you give that person legal permission to act as your appointed representative for your coverage decision. Please submit this form to our Appeals Department at the address provided in the previous paragraph. If you prefer you may fax the form to the fax number also provided in that section.

What happens when I request a coverage decision?
What happens, including how soon we will decide, depends on the type of decision you request.

For a standard coverage decision, including requests for payment for a drug you have already received, we generally are required to give you our decision no later than 72 hours after we receive your request. We will make it sooner if your health condition requires.

However, if your request is for an exception (including a formulary exception, tiering exception, or an exception from utilization management rules), we must make our decision no later than 72 hours after we receive your doctor’s supporting statement (use the Prior Authorization Form), which explains why the drug you are asking for is medically necessary. If you are requesting an exception, you should submit your prescribing doctor’s supporting statement (use the Prior Authorization Form) with your request, if possible.

If we have not given you an answer within 72 hours after receiving your request, your request will automatically go to Appeal Level 2, where an independent organization will review your case.

If you qualify for a fast coverage decision about a Part D drug you have not received, we will give you our decision within 24 hours — sooner if your health requires. If you are requesting a fast exception, we are required to make our decision no later than 24 hours after we get a supporting statement (use the Coverage Decision Form) from your doctor, explaining why the non-formulary or non-preferred drug you are asking for is medically necessary.

We will give you our decision in writing. If we do not approve your request for either a standard or fast decision, we will explain why, and tell you of your right to appeal our decision.

How soon will my coverage decision be decided?
We will make a decision whether we will cover a Part D prescription in either 72 or 24 hours. A standard coverage decision is usually made within 72 hours and a fast coverage decision is made more quickly (typically within 24 hours; see below). A fast decision is sometimes called an expedited coverage decision. You may seek a fast decision only if you or your doctor believes that waiting for a standard decision could seriously harm your health or your ability to function. NOTE: Fast decisions apply only to requests for Part D drugs that you have not received yet. You cannot get a fast decision if you are requesting payment for a Part D drug that you already received.

If your doctor requests, or supports your request for a fast decision, and indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you a fast decision.

If you ask for a fast coverage decision without support from a doctor, we will decide if your health requires a fast decision. If we decide that your medical condition does not meet fast coverage requirements, we will send you a letter informing you that we will supply a fast decision if you get a doctor’s support. The letter will also tell you how to file a grievance if you disagree with our decision. If we deny your request for a fast review, we will give you our decision within the 72-hour standard timeframe.

What happens if my request is denied?
If we deny your request, we will send you a written explanation. We may decide completely or only partly against you. For example, if we deny your request for payment for a drug you have already received, we may pay nothing or only part of the amount you requested. If a coverage decision does not give you all you requested, you have the right to appeal the decision.

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Appeals
Grievances and Appeal Policies