What Is a Coverage Determination? 

A Coverage determination is a decision made by our plan (not the pharmacy) about your prescription drug benefits, including whether a particular drug is covered, whether you have met all the requirements for getting a requested drug, how much you’re required to pay for a drug, and whether to make an exception to a plan rule when you request it.   

If a drug is not covered on our plan, you can ask the plan to make an “exception.” An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision. 

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request.   

A Coverage determination may be requested by any of the following: 

• You or your representative may request a coverage determination. 

• Your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) can request a coverage determination for you on your behalf. 
   

A coverage determination may be requested for any of the following: 

• Covering a Part D drug for you that is not on your plan’s List of Covered Drugs (Formulary). 

• You may ask our plan for an exception if you or your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) believes you need a drug that isn’t on your drug plan’s list of covered drugs. 

• You may ask for an exception if your network pharmacy can’t fill a prescription as written. 

• Removing a restriction on the plan’s coverage for a covered drug. 

• You may ask for an exemption if you or your prescriber believe that a coverage rule (such as a prior authorization) should be waived. 

• Changing coverage of a drug to a lower cost-sharing tier. (Tier Exception) 

• You may ask for an exception if you think you should pay less for a higher tier drug because you or a your prescriber believe you can’t take any of the lower tier drugs for the same condition. 

• Request for payment. 

• You may ask us to pay for a prescription that you already paid for.  
   

Your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception. For a faster decision, include medical information from your doctor or other prescriber when you ask for the exception. 

Our plan can accept or deny your request. 

If we approve your request for an exception, our approval usually is valid until the end of the plan year. This is true if your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition. 

If we say no to your request for an exception, you can ask for a review of our decision by making an appeal. If your health requires a quick response, you must ask us to make a “fast decision.” 
 

This section provides specific information of particular importance to our Cooperative Advantage Members receiving Part D drug benefits. Below are links to forms applicable to Part D grievances, coverage determinations (including exceptions) and appeals processes.    

A Member, a Member’s representative, or a Member’s prescriber may use the Request for a Medicare Prescription Drug Determination Form to request a coverage determination, including an exception, from Cooperative Advantage.    

A Member, a Member’s representative, or a Member’s prescriber may use the Request for a Medicare Prescription Drug Redetermination Form to request a redetermination (appeal) from Cooperative Advantage.   

A Member or a Member’s representative may use the Request for Reconsideration of Medicare Prescription Drug Denial Form to request a reconsideration with the Independent Review Entity.    

Federal regulations at 42 CFR § 423.800 specify the requirements of Part D sponsors in the administration of the low-income subsidy program, including the reduction of cost sharing for subsidy-eligible individuals. In certain cases, CMS systems do not reflect a beneficiary’s correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan. 

To address these situations, CMS created the best available evidence (BAE) policy in 2006. This policy requires sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary’s information is not accurate. 

For more information, please view the best available evidence (BAE) policy.