Coverage Determinations

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 that is entitled to. A coverage determination is any decision done by the plan related to:

• A prescription that a patient believes should be covered
• A payment for a prescription that the patient believes should be covered
• An exception request to the level of copay or to the formulary
• Member disagreement with the quantity that the plan requires the member to pay for a Part D drug
• Member disagreement with the quantity limit
• Member disagreement with the requirements for step therapy (the member has to try another drug before the approval of the requested drug)
• Member disagreement or dissatisfaction with a decision, preauthorization or requirement of utilization management
• If your doctor or pharmacy informs you that a drug is not covered by the plan, you should contact your plan to request a coverage determination.

The coverage determination can be requested by the member's physician, the member, or a representative designated by the member. The request can be done verbally or in writing.

If the request does not involve an exception, the member will be notified within 24 hours (expedite request) or within 72 hours (standard request). If it is an exception request, this period starts when the physician statement is received. If the request is denied, the decision will be notified along with the information needed to request a redetermination.

For more information about coverage determinations you can contact the Member Services Department at 787-625-2126 (Metro Area), 1-866-516-7700 (toll free), or 1-866-516-7701 TTY (hearing impaired). You may also refer to Section 9 of your Evidence of Coverage.