Coverage Determinations, Exceptions and Redeterminations

Under Part D (prescription drug benefit) program, a member can ask for a coverage determination regarding the drug benefits they are entitled to receive. A coverage determination is a decision made by or on behalf of a Part D plan regarding payment or benefits to which a member believes he or she is entitled. This includes asking our plan to make an exception to the way a drug is covered.

A coverage determination is any decision made by the plan regarding:

  • Receipt of, or payment for, a prescription drug that a member believes may be covered;
  • A tiering or formulary exception request;
  • The amount that the plan requires a member to pay for a Part D prescription drug and the member disagrees with the plan;
  • A limit on the quantity (or dose) of a requested drug and the member disagrees with the requirement or dosage limitation; and
  • A decision whether a member has, or has not, satisfied a prior authorization or other utilization management requirement.

A member, a member’s representative, or a member’s prescriber may submit a request for coverage determination, including an exception by fax, mail or phone.  Please see below chart for contact information for your plan coverage.

Drug Coverage Determination Form By mail:  By fax: By phone:

 

HMO Drug Coverage Determination Form...Coming Soon

*You cannot use this form for Medicare non-covereddrugs: fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over the counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).               

<Address>                                                                                                                                                                     <Fax number>                                                                                                                                              <Phone number>  (TTY: 711)                                                                                                                        
Drug Coverage Determination Form By mail:  By fax: By phone:

 

HMO SNP Drug Coverage Determination Form...Coming Soon

*You cannot use this form for Medicare non-covereddrugs: fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over the counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).               

<Address>                                                                                                                                                                        

<Fax number>                                                                                                                                             <Phone number>(TTY: 711)                                                                                                                     
Drug Coverage Determination Form By mail:  By fax: By phone:

 

PPO Drug Coverage Determination Form...Coming Soon

*You cannot use this form for Medicare non-covereddrugs: fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over the counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).               

<Address>                                                                                                                                         

<Fax Number>                                                                                                                                               <Phone Number> (TTY: 711)                                                                                                                     
By mail: By fax:By phone:

 

HMO Drug Coverage Determination Form...Coming Soon

*You cannot use this form for Medicare non-covereddrugs: fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over the counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).               

Envolve Pharmacy Solutions-Medicare Prescription Drug Plan
5 River Park Place East
Suite 210
Fresno, CA 93720                                                                                                                                                                        

1-877-941-0480                                                                                                                                             1-877-935-8022 (TTY: 711)                                                                                                                     

What if I have an urgent request?

If the member believes waiting 72 hours for a standard decision could seriously harm their life, health, or ability to regain maximum function, they can ask for an expedited decision. If the prescriber indicates that waiting 72 hours could seriously harm the member’s health, a decision will be made within 24 hours after receipt from the prescriber of a supporting statement.

Once approves an exception, we cannot require a member to request approval for a refill or new prescription to continue using the Part D prescription drug approved under the exceptions process for the remainder of the plan year. In order to keep the exception in place for the whole year, the member must remain enrolled in the plan, the member’s physician or other prescriber must continue to prescribe the drug, and the drug must be safe for treating the member’s condition.

When a decision is made, the member will receive a written notification detailing the outcome including member appeal rights for any requests that have been denied.

If changes its formulary or the cost-sharing status of a drug during the plan year, we will give written notice to affected enrollees at least 60 days in advance of the change becoming effective. If is unable to give a 60-day advance notice, we will supply the drug affected by the change and give written notice at the time of refill. For process or status questions, you or your provider can call us to speak to someone in Member Services.

Redeterminations

If we deny your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You, your prescriber, or your representative may ask us for an appeal. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination. You may request a redetermination by completing the Request for Redetermination of Medicare Prescription Drug Denial form but you are not required to use this form. You can send us the form, or other written request, by mail or fax to:

Centene Corporation
<Address>
Fax: <fax number>

Expedited appeal requests can be made by phone at <Phone number> (TTY: 711) for HMO members or <Phone number> (TTY: 711) for HMO SNP [PPO] members.

If you or your prescriber believe that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 7 days could seriously harm your health, we will automatically give you a decision within 72 hours. If you do not obtain your prescriber’s support for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

HMO Request for Redetermination Form...Coming Soon

Please select the form for your county:

County  Redetermination Form 

HMO SNP Redetermination Form 

HMO SNP Redetermination Form 

HMO SNP Redetermination Form 

HMO SNP Redetermination Form 

[2018_COUNTIES_SNP_005] HMO SNP Redetermination Form 
[2018_COUNTIES_SNP_006] HMO SNP Redetermination Form 

HMO SNP Redetermination Form 

HMO SNP Redetermination Form 

PPO Request for Redetermination Form...Coming Soon

Reconsideration 

Please select the form for your county:

County Reconsideration


HMO Reconsideration Form 

HMO Reconsideration Form 

HMO Reconsideration Form 

HMO Reconsideration Form 

[2018_COUNTIES_HMO_005] HMO Reconsideration Form 
[2018_COUNTIES_HMO_006] HMO Reconsideration Form 

Please select the form for your county:

COUNTY RECONSIDERATION


HMO SNP Reconsideration Form 

HMO SNP Reconsideration Form 

HMO SNP Reconsideration Form 

HMO SNP Reconsideration Form 

[2018_COUNTIES_SNP_005] HMO SNP Reconsideration Form 
[2018_COUNTIES_SNP_006] HMO SNP Reconsideration Form 

HMO SNP Redetermination Form 

HMO SNP Redetermination Form 

HMO Reconsideration Form 
HMO Reconsideration Form 

PPO Request for Reconsideration Form...Coming Soon

Medicare Hospice Forms (for provider use only):

HMO Medicare Hospice Form…Coming Soon

HMO SNP Medicare Hospice Form…Coming Soon

PPO Medicare Hospice Form…Coming Soon

Last Updated: 02022017
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