2015 Member Decisions
For a full explanation of medical and prescription drug coverage decisions, formulary exceptions, medical and prescription drug appeals, and grievances, see your 2015 Evidence of Coverage (Chapter 9 – What to do if you have a problem or complaint (coverage decisions, appeals, complaints):
2015 Evidence of Coverage
Coverage decisions are "determinations" about what tests, treatment services, and prescription drugs are covered or paid for under your health plan. These decisions are guided by Medicare coverage guidelines as well as what is medically necessary, appropriate, and safe. Your physician makes most decisions about your medical care, and Care Improvement Plus works with providers to help assure that you receive the covered benefits you need.
You can read about coverage decisions regarding your prescription drugs in the section that follows.
Prescription Drug Decisions and Exceptions
A decision whether a prescription drug will be covered under the health plan is called a "coverage determination." Like most health plans, Care Improvement Plus uses a "formulary" to set out its drug coverage. A formulary is a comprehensive plan that includes a list of all the drugs covered under the benefit as well as dosage amounts and form of administration, a member cost-sharing structure known as copayment ’tiers,“ and, for certain drugs, pre-authorization requirements and quantity limits.
We have teamed up with pharmacy benefit experts at OptumRx to help make coverage determinations using the formulary and to work with your physician. We work together to ensure that prescriptions are covered under the plan, filled timely, and are safe for you.
Coverage determinations include, but are not limited to:
- prior authorizations by OptumRx before a pharmacy may dispense certain drugs,
- limits set by OptumRx 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 as discussed below
- determinations made by OptumRx as to whether select prescription drugs should be covered and billed under Medicare Part B, or Medicare Part D
You, your authorized representative, or your prescribing physician may request a coverage determination.
Decisions for Prior authorization coverage determinations are made within 72 hours of the request,
unless your health is in jeopardy and a request is made for a fast-track decision. We verify the need for a
fast-track decision and then make an expedited decision as quickly as possible - within 24 hours of the request.
If coverage is denied, you will be notified and receive a written explanation with appeal rights. If your request for a fast-track decision is denied and you disagree, you may file an expedited grievance. You are always notified of our decisions.
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.
Exceptions - In some cases, it may be medically necessary and appropriate for you to have an
"exception" to the formulary. Exceptions are requests for a non-formulary drug, a lower copayment tier, or to
remove the formulary's pre-authorization requirements or quantity limits. You, your authorized representative,
or your physician may request the exception by phone, fax, or mail. There is a
form that you may use and another
form for physicians. For all exception requests, your physician must provide information that supports the medical
basis for the exception. Care Improvement Plus will issue a decision within
72 hours, or 24 hours (if expedited), of receiving complete supporting information
from your physician or other prescriber. If your exception request is denied you will
receive a written notice with your appeal rights
Appointment of Representative form
- 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. A physician may request a coverage
determination on a member’s behalf without appointment of representative form.
Authorization to Release Form
- An authorized representative is an individual who is granted, by the member,
the right to discuss and/or receive the member’s personal health information.
Medicare Partners do not have the authority to make changes to the member’s
account or to take action on behalf of the member. Not to be misconstrued/used
as an Appointment of Representative.
For prescription drug determinations, physicians may act on behalf of the beneficiary and do not need the authority just described.
This page was last updated on: 8/12/2014 3:44:38 PM