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Coverage Determinations and Exceptions
A coverage determination is the initial decision made by, or on behalf of, a Part D plan sponsor regarding payment or benefits to which an enrollee believes he/she is entitled to.
A coverage determination is any decision made by the plan related to:
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A prescription that a patient believes should be covered
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A payment for a prescription that the patient believes should be covered
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A request for an exception to the level of copay or to the Formulary
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Member disagrees with the amount that the plan requires the member to pay for a Part D drug
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Member disagrees with the quantity limit
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Member disagrees with the requirements for step therapy (the member has to try another drug before the approval of the requested drug)
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Member disagreement or dissatisfaction with a decision, preauthorization, or requirement of utilization management
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If your doctor or pharmacy informs you that the plan does not cover a drug, you should contact your plan to request a coverage determination
The coverage determination may be requested by your doctor, you as a Member, or an authorized representative who has completed the plan’s required Appointment of Representative document. The request may be made orally or in writing. To protect your privacy and to confirm your identity, a representative of our plan could contact you, your doctor, or authorized representative, to ask you for additional information or documentation.
Exceptions: What should you do?
An exception is a type of coverage determination. You can ask us to make an exception to our coverage rules in a number of situations:
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You may request us to cover your drug even if it is not on our Formulary. Excluded drugs cannot be covered by a Part D plan unless coverage is through an enhanced plan.
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You may request that we waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
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You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our non-preferred/highest tier, subject to the tier exception process, you may request us to cover it at the cost-sharing amount that applies to drugs in the preferred/lowest tier, subject to the tier exception process instead. This will lower the coinsurance/copay amount you must pay for your prescription. Please note that if we grant your request to cover a drug that is not on our Formulary, you may not ask us to provide a higher level of coverage for the drug.
Generally, we will only approve your request for an exception if the alternative drugs included in the plan Formulary or the drugs in the non-preferred/highest tier subject to the tier exception process would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
Your physician must submit a statement supporting your exception request. In order to help us make a decision more quickly, you should include supporting medical information from your doctor when you submit your exception request. The plan will issue a decision on the case in a period of 72 hours (standard request) after receiving the written statement from your doctor. If you believe that the 72-hour review period may adversely affect your health, you may request an expedited decision. Simply state in the request that an expedited review is necessary, and a decision will be issued within a period of 24 hours or less from the receipt of the doctor’s statement.
If we approve your exception request, our approval is valid for the rest of the plan year, as long as your doctor continues to prescribe the drug for you and it continues to be safe and effective for treating your condition. If we deny your exception request, you can appeal our decision.
Note: If we approve your exception request for a non-formulary drug, you cannot request an exception to the copay or coinsurance amount we require you to pay for the drug.
To learn more about how to request a standard exception or expedited exception, see the “What is an exception?” section of your plan’s Evidence of Coverage or call Member Services. Plans are expected to disclose exception data, upon request, to individuals eligible to elect a Medicare Advantage organization or a Part D Sponsor. If you are interested in receiving this information, please contact Member Services.
Healthcare Providers:
Prior Authorization Submission:
FAX: (858) 790-7100
The following link may be used to also electronically submit a PA request. Please note validation on member and plan details is required for complete submission: https://mp.medimpact.com/partdcoveragedetermination
ePA Submission:
Conveniently submit requests at the point of care through the patient’s electronic health record.
If the EMR/EHR does not support ePA, you can use one of these vendor portals: