A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your Part D drugs.
Here are examples of coverage decisions you ask us to make about your Part D drugs. An initial coverage decision about your Part D drugs is called a “coverage determination.”
- You ask us to make an exception, including:
- Asking us to cover a Part D drug that is not on the Plan’s formulary.
- Asking us to waive a restriction on the Plan’s coverage for a drug (such as limits on the amount of the drug you can get).
- You ask us whether a drug is covered for you and whether you satisfy any applicable coverage rules.
- You ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment.
If you disagree with a coverage decision we have made, you can appeal our decision. For more information, please refer to Chapter 9 in your Evidence of Coverage (EOC).
Step-by-step: How to ask for a Coverage Decision, Including an Exception
Step 1: You 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.
Request the type of coverage decision you want. Start by calling, writing, or faxing our plan to make your request. You, your representative, or your doctor (or other prescriber) can do this.
You can contact our Member Services.
A written request may be made using the Medicare Prescription Drug Coverage Determination Request Form.
The Medicare Part D Coverage Determination Request Form is not required to request a coverage decision. Our plan is required to accept any request that is made in writing (when made by a Member, a Member’s prescribing physician or other prescriber, or a Member’s appointed representative) and is prohibited from requiring a Member or physician, or other prescriber to make a written request on a specific form.
The written request can be mailed, delivered in person, CCHP, 445 Grant Avenue, San Francisco, CA 94108 or faxed to: 1-415-397-2129.
- If you want to ask our Plan to pay you back for a drug, see Chapter 7 in the Evidence of Coverage.
- If you are requesting an exception, provide the “doctor’s statement,” giving us the medical reasons for the drug exception you are requesting.
- 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 have 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.
Step 2: Our plan considers your request and we give you our answer.
If we are using the fast deadlines, we must give you our answer within 24 hours.
- If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 24 hours after we receive your request or the doctor’s statement supporting your request.
- If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.
If we are using the standard deadlines, we must give you our answer within 72 hours.
- If our answer is yes to part or all of what you requested–If we approve your request for coverage, we must provide the coverage we have agreed to provide within 72 hours after we receive your request or doctor’s statement supporting your request.
- If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.
Deadlines for a “standard” coverage decision about payment for a drug you have already bought–We must give you our answer within 14 calendar days after we receive your request.
- If our answer is yes to part or all of what you requested, we are also required to make payment to you within 14 calendar days after we receive your request.
- If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.
Step 3: If we say no to your coverage request, you decide if you want to make an appeal.
If our Plan says no, you have the right to request an appeal. Requesting an appeal means asking us to reconsider—and possibly change—the decision we made. For more information, please refer to Chapter 9 in your Evidence of Coverage.