Part D Coverage Determinations and Exceptions

• 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 you 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: 711)
By mail:
Medco Health Solutions, Inc.
Attn: Medicare Reviews
P.O. Box 63067
Irving, TX 75063-0118

If your 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. You or your 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. You, your prescribing physician, and/or your authorized representative may request an exception to the formulary, a quantity limit, or other coverage determination on your behalf. To help the process, you or your authorized representative may use the Coverage Determination Request Form or contact us using the information provided below.

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 you submit 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.

Prescribing physicians may request coverage determinations, exceptions, and/or appeals on your behalf without being an authorized representative.

Evidence of Coverage

For a full explanation of medical and prescription drug coverage decisions, formulary exceptions, medical and prescription drug appeals, and grievances, see your 2011 Evidence of Coverage (Chapter 9 – What to do if you have a problem or complaint (coverage decisions, appeals, complaints):

• Care Improvement Plus Silver Rx (Regional PPO SNP)
• Care Improvement Plus Silver Rx (PPO SNP)
• Care Improvement Plus Gold Rx (Regional PPO SNP)
• Care Improvement Plus Gold Rx (PPO SNP)
• Care Improvement Plus Dual Advantage (Regional PPO SNP)
• Care Improvement Plus Dual Advantage (PPO SNP)
• Care Improvement Plus Medicare Advantage (Regional PPO)
• Care Improvement Plus Medicare Advantage (PPO)