Part D Coverage Determinations and Exceptions
Coverage determinations include:
- prior authorizations by Medco before a pharmacy may dispense certain drugs,
- limits set by Medco on the quantity or amount that can be dispensed of certain drugs,
- a decision to pay a claim for a drug that has been paid for,
- a decision whether a prescribed drug is medically necessary, appropriate, or used for an FDA-approved indication, and
- a request for an exception to the formulary
Prior Authorization
Members will need to get prior authorization for certain drugs on our formulary. Drugs will need a prior authorization (PA) if they have a B/D, ST and/or a PA next to them on the formulary. Members or their provider can call 1-800-753-2851 to request a prior authorization. Click
here for more information regarding criteria for medications that require prior authorization.
Timelines for prior authorizations are very prompt. Decisions are made within 72 hours, unless an expedited decision is needed. In expedited cases, the decision will be made as quickly as possible but no later than 24 hours from time of request. The expedited track is used when the longer (72 hour) period could jeopardize the life, health or ability of an enrollee to regain maximum function.
For prescription drug coverage determinations (such as prior authorizations), inquiries, or a status update on a coverage request but not exception requests, contact Medco.
By phone: 1-800-753-2851 (TTY:1-800-713-1603)
By mail:
Medco Health Solutions, Inc.
Attn: Medicare Reviews
P.O. Box 63067
Irving, TX 75063-0118
If a member’s physician would like to request a prior authorization through our online service; they can click here.
Exceptions
Exceptions are requests for coverage of a non-formulary drug, coverage of a formulary drug at a lower copayment tier, or to remove the formulary's pre-authorization requirements or quantity limits. In some cases, it may be medically necessary and appropriate for the Care Improvement Plus enrollee to have an "exception" to the formulary. The enrollee or provider may request the exception by phone, fax, or mail using the contact information below. Exception requests are made directly to Care Improvement Plus, where pharmacy and medical clinicians will make a determination. Decisions for standard exception requests are made no later than 72 hours of receiving complete supporting information from the physician. Determinations for expedited requests are made no later than 24 hours of receipt of complete supporting information from the physician.
The member, prescribing physician, and/or authorized representative may request an exception to the formulary, a quantity limit, or other coverage determination. To request an exception, a provider may use the
Provider Medicare Part D Exception Request
For formulary exceptions requests, contact Care Improvement Plus.
By phone: 1-800-204-1002 (TTY: 711)
By fax: 1-866-683-3272
By email: PartDexceptionsandappeals@careimprovementplus.com
Claims-If a member submits a claim for a prescription filled outside of our national network of pharmacies or at a physician's office, Care Improvement Plus will issue a written determination, including an explanation of appeal rights if any part of the claim is denied.
Authorized Representative - Requests may be made by a family member, friend, or other party if the individual
demonstrates legal authority, such as a medical power of attorney. Another way to be delegated this authority is by
submitting to the plan a signed Appointment of Representative form.
This page was last updated on: 9/23/2011 3:18:12 PM