Part D Coverage Determinations and Exceptions
Coverage determinations include:
- 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
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. 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 determination request, contact Member Services.
By phone: 1-800-204-1002 (TTY: 711) for members; providers can contact OptumRx at
Prior Authorization Dept. CA 106-0286
3515 Harbor Blvd.
Costa Mesa, CA 92626
If your physician would like to request a prior authorization through our online service; they can
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 to the OptumRx PA Department, 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) for members; providers can contact OptumRx
By fax: 1-800-527-0531
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.
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.
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 2015 Evidence of Coverage (Chapter 9 – What to do if you have a problem or complaint (coverage decisions, appeals, complaints):
This page was last updated on: 9/2/2014 8:02:40 AM