Coverage Determination

How to Request a Coverage Determination

What is a coverage determination?

Whenever you ask for a Part D prescription drug benefit, the first step is called requesting a coverage determination. When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exceptions requests. You have the right to ask us for an “exception” if you believe you need a drug that is not on our list of preferred drugs (formulary) or believe you should get a drug at a lower co-payment. If you request an exception, your physician must provide a statement to support your request.

You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination.

If you have problems getting the prescription drugs you believe we should provide, you can request a coverage determination. We use the word “provide” in a general way to include such things as authorizing prescription drugs, paying for prescription drugs, or continuing to provide a Part D prescription drug that you have been getting.

If your doctor or pharmacist tells you that Elderplan will not cover a prescription drug, you should contact us and ask for a coverage determination. The following are examples of when you may want to ask us for a coverage determination:

  • If you are not getting a prescription drug that you believe may be covered by Elderplan.
  • If you have received a Part D prescription drug you believe may be covered by Elderplan 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 preferred drugs (also 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 you to pay for a drug.
  • 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 there is a requirement that you try another drug before we will pay for the drug you are requesting.
  • You bought a drug at a pharmacy that is not in our network and you want to request reimbursement for the expense.

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How to request a coverage determination

The purpose of this section is to give you more information about how to request a coverage determination, or appeal a decision by us not to cover or pay for all or part of a drug, vaccine or other Part D benefit.

When we make a coverage determination, we are giving our interpretation of how the Part D prescription drug benefits that are covered for members of Elderplan apply to your specific situation. Elderplan makes a coverage determination about your Part D prescription drug or about paying for a Part D prescription drug you have already received. The coverage determination made by Elderplan is the starting point for dealing with requests you may have about covering or paying for a Part D prescription drug. If your doctor or pharmacist tells you that a certain prescription drug is not covered, you should contact Elderplan and ask us for a coverage determination. With this decision, we explain whether we will provide the prescription drug you are requesting or pay for a prescription drug you have already received. If we deny your request (this is sometimes called an “adverse coverage determination”), you can appeal the decision by going on to Appeal Level 1. If we fail to make a timely coverage determination on your request, it will be automatically forwarded to the independent review entity, Appeal Level 2, for review.

The following are examples of coverage determinations:

  • You ask us to pay for a prescription drug you have already received. This is a request for a coverage determination about payment. You can call us at 1-866-417-3064, 24 hours a day, 7 days a week (for TTY, call 1-866-763-9630), to get help in making this request.
  • You ask for a Part D drug that is not on Elderplan’s list of preferred drugs (also called a formulary). This is a request for a “formulary exception.” You can call us at 1-866-417-3064, 24 hours a day, 7 days a week (for TTY, call 1-866-763-9630), to ask for this type of decision.
  • You ask for an exception to our plan’s utilization management tools—such as dosage limits, quantity limits or step therapy requirements. Requesting an exception to a utilization management tool is a type of formulary exception. You can call us at 1-866-417-3064, 24 hours a day, 7 days a week (for TTY, call 1-866-763-9630), to ask for this type of decision.
  • You ask for a non-preferred Part D drug at the preferred cost-sharing level. This is a request for a “tiering exception.” You can call us at 1-866-417-3064, 24 hours a day, 7 days a week (for TTY, call 1-866-763-9630), to ask for this type of decision.
  • You ask that we reimburse you for a purchase you made from an out-of-network pharmacy. In certain circumstances, out-of-network purchases, including drugs provided to you in a physician’s office, will be covered by the plan. You can call us at 1-866-417-3064, 24 hours a day, 7 days a week (for TTY, call 1-866-763-9630), to make a request for payment or coverage for drugs provided by an out-of-network pharmacy or in a physician’s office.

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Who may ask for a coverage determination?

You can ask us for a coverage determination yourself, or your prescribing physician or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor or anyone else to act for you. Some other persons may already be authorized under state law to act for you. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. This statement, Appointment of Representative Form, must be sent to us at:

Envision Pharmaceuticals
2181 East Aurora Road, Suite 201
Twinsburg, OH 44087

Or you may fax it to: 1-330-405-8081

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.

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Standard vs. fast coverage determination

Do you have a request for a Part D prescription drug that needs to be decided more quickly than the standard timeframe? A decision about whether we will cover a Part D prescription drug can be a “standard” coverage determination that is made within the standard timeframe (typically within 72 hours), or it can be a “fast” coverage determination that is made more quickly (typically within 24 hours). A fast decision is sometimes called an “expedited coverage determination.”

You can ask for a fast decision only if you or your doctor believe that waiting for a standard decision could seriously harm your health or your ability to function. 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.

Standard Coverage Determination

To ask for a standard decision, you, your doctor or your appointed representative should call us at 1-866-417-3064, 24 hours a day, 7 days a week (for TTY, call 1-866-763-9630). Or, you can mail a written request, or completed Request for Coverage Determination Form, to:

Envision Pharmaceuticals
2181 East Aurora Road, Suite 201
Twinsburg, OH 44087

Or you may fax it to: 1-330-405-8081

Fast Coverage Determination

You, your doctor or your appointed representative can ask us to give a fast decision (rather than a standard decision) by calling us at 1-866-417-3064, 24 hours a day, 7 days a week (for TTY, call 1-866-763-9630).Or, you can mail a written request, or completed Request for Coverage Determination Form, to:

Envision Pharmaceuticals
2181 East Aurora Road, Suite 201
Twinsburg, OH 44087

Or you may fax it to: 1-330-405-8081

Be sure to ask for a “fast,” “expedited,” or “24-hour” review.

  • If your doctor asks for a fast decision for you or supports you in asking for one, and the doctor 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 determination 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 the requirements for a fast coverage determination, we will send you a letter informing you that if you get a doctor’s support for a fast review, we will automatically give you a fast decision. The letter will also tell you how to file a grievance if you disagree with our decision to deny your request for a fast review. If we deny your request for a fast coverage determination, we will give you our decision within the 72-hour standard timeframe.

Certain drugs require supporting documentation from your physician (non-formulary and tiering exceptions, prior authorizations, step therapies, quantity limits). Your physician may use the available forms (or ANY other written forms) to assist in this process.

Medication Exception Request Form For Non-Formulary Drug, Quantity Limit and Step Therapy English/Spanish
Tier Exception Request Form English/Spanish
Prior Authorization Request Form English/Spanish
Prior Authorization Request Form: Aranesp, Epogen, and Procrit English/Spanish
Member Reimbursement Form

“Physicians assisting with coverage determinations may also use the Request for Coverage Determination Form.”

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How quickly are coverage determination decisions made?

Standard Coverage Determination: For a standard coverage determination about a Part D drug, which includes a request about payment for a Part D drug that you already received, generally, we must give you our decision no later than 72 hours after we have received your request, but we will make it sooner if your health condition requires. However, if your request involves a request for an exception (including a formulary exception, tiering exception or an exception from utilization management rules—such as dosage or quantity limits or step therapy requirements), we must give you our decision no later than 72 hours after we have received your physician’s supporting statement, which explains why the drug you are asking for is medically necessary. If you are requesting an exception, you should submit your prescribing physician’s supporting statement with the request, if possible.

We will give you a decision in writing about the prescription drug you have requested. If we do not approve your request, we must explain why and tell you of your right to appeal our decision. Appeal Level 1 explains how to file this appeal. If you have not received an answer from us within 72 hours after we have received your request, your request will automatically go to Appeal Level 2, where an independent organization will review your case.

Fast Coverage Determination: For a fast coverage determination about a Part D drug that you have not received, we will give you our decision within 24 hours after you or your doctor ask for a fast review—sooner if your health requires. If your request involves a request for an exception, we will give you our decision no later than 24 hours after we have received your physician’s supporting statement, which explains why the non-formulary or non-preferred drug you are asking for is medically necessary.

We will give you a decision in writing about the prescription drug you have requested. If we do not approve your request, we must explain why and tell you of your right to appeal our decision. Appeal Level 1 explains how to file this appeal. If we decide you are eligible for a fast review, and you have not received an answer from us within 24 hours after receiving your request, your request will automatically go to Appeal Level 2, where an independent organization will review your case.

If we do not grant your or your physician’s request for a fast review, we will give you our decision within the standard 72-hour timeframe discussed above. If we tell you about our decision not to provide a fast review by phone, we will send you a letter explaining our decision within three calendar days after we call you. The letter will also tell you how to file a grievance if you disagree with our decision to deny your request for a fast review and will explain that we will automatically give you a fast decision if you get a doctor’s support for a fast review.

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What happens if we decide completely in your favor?

If we make a coverage determination that is completely in your favor, what happens next depends on the situation.

Standard Coverage Determination: For a standard decision about a Part D drug, which includes a request about payment for a Part D drug that you already received, we must authorize or provide the benefit you have requested as quickly as your health requires, but no later than 72 hours after we received the request. If your request involves a request for an exception, we must authorize or provide the benefit no later than 72 hours after we have received your physician’s supporting statement. If you are requesting reimbursement for a drug that you already paid for and received, we must send payment to you no later than 30 calendar days after we receive the request.

Fast Coverage Determination: For a fast decision about a Part D drug that you have not received, we must authorize or provide you with the benefit you have requested no later than 24 hours after receiving your request. If your request involves a request for an exception, we must authorize or provide the benefit no later than 24 hours after we have received your physician’s supporting statement.

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What happens if we deny your request?

If we deny your request, we will send you a written decision explaining the reason why your request was denied. We may decide completely or only partly against you. For example, if we deny your request for payment for a Part D drug that you have already received, we may say that we will pay nothing or only part of the amount you requested. If a coverage determination does not give you all that you requested, you have the right to appeal the decision.

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