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National Home Members Prescription Information Part D Coverage Determinations & Exceptions

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

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. 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 1-800-711-4555

By mail:

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 click here.


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 at 1-800-711-4555
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

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Additional Information Links State Health Plan Links
Providers Support
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Regional PPO Plans
Medicaid / Medicare Special Needs Plans
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Medicare Coverage - Diabetes
Medicare Coverage - Heart Failure
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Wisconsin Medicare Health Plans

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan’s contract renewal with Medicare. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or by another third party.

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Medicare evaluates plans based on a 5-Star rating system. Star ratings are calculated each year and may change from one year to the next.

Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity and restrictions may apply. It may cost more to get care from out–of–network providers, except in an emergency. If there isn’t a network provider available for you to see, you can go to an out–of–network provider but still pay the in–network amounts. The health providers in our network can change at any time.

To be eligible for a Care Improvement Plus Regional PPO plan you must be a Medicare beneficiary living in Arkansas, Georgia, Missouri, South Carolina, or Texas and have both Medicare Part A and Part B to enroll.

To be eligible for a Care Improvement Plus Local PPO plan you must be a Medicare beneficiary living in select counties of: Arkansas, Georgia, Illinois, Indiana, Iowa, Missouri, Nebraska, New Mexico, North Carolina, South Carolina, Texas or Wisconsin and have both Medicare Part A and Part B to enroll.

To be eligible for a Care Improvement Plus Chronic Conditions Special Needs Plan, you must have diabetes and/or heart failure and/or, cardiovascular disorder. This plan is available to anyone having a qualifying chronic care condition. Members may enroll in the plan only during specific times of the year. Contact Care Improvement Plus for more information. If you have diabetes, heart failure, cardiovascular disorder or Medicaid/Low Income Subsidy, you may qualify to enroll in a Care Improvement Plus Special Needs Plan ANYTIME of the year by exercising a “Special Election Period.

To be eligible for a Care Improvement Plus Dual Advantage Plan, you must be enrolled in state Medicaid and be a dual eligible beneficiary whom the State holds harmless for Part A and Part B cost sharing. This plan is available to anyone who has both medical assistance from the state and from Medicare. If you are a full benefit dual beneficiary and your Part B premium is paid for by the State, you will not be responsible for paying your Part B premium. Premiums, copays, co-insurance and deductibles may vary based on the level of extra help you receive. Please contact the plan for further details.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call:

  • 1–800–MEDICARE (1–800–633–4227). TTY users should call 1–877–486–2048, 24 hours a day/7 days a week;
  • The Social Security Office at 1–800–772–1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1–800–325–0778; or
  • Your State Medicaid Office.

People with limited incomes may qualify for Extra Help to pay their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office, or call Social Security at 1– 800–772–1213.TTY users should call 1–800–325–0778. You can also apply for Extra Help online at www.socialsecurity.gov/prescriptionhelp. If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a part of this premium, we will bill you for the amount that Medicare doesn’t cover.

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