A coverage determination is the first decision we make about covering the drug you are requesting. If your doctor or pharmacist tells you that a certain prescription drug is not covered, you may contact us at (888) 456-4715 if you want to request a coverage determination.

Requesting a Coverage Determination

The following explains what you can do if you have problems receiving the prescription drugs you believe we should provide and you want to request a coverage determination. We use the word “provide” in a general way to include such things as authorizing prescription drugs, paying for prescription drugs, or continuing to provide a Part D prescription drug that you have been receiving.

What is a Coverage Determination?

The coverage determination we make is the starting point for dealing with requests you may have about covering or paying for a Part D prescription drug. If your doctor or pharmacist tells you that a certain prescription drug is not covered, you should contact us and ask us for a coverage determination. With this decision, we explain whether we will provide the prescription drug you are requesting or pay for a prescription drug you have already received. If we deny your request (this is sometimes called an “adverse coverage determination”), you may “appeal” the decision by going on to Appeal Level 1 (see your Evidence of Coverage). If we fail to make a timely coverage determination on your request, it will be automatically forwarded to the independent review entity for review (see your Evidence of Coverage).

What is an Exception?

An exception is a type of coverage determination. You may ask us to make an exception to our coverage rules in a number of situations.

• You may ask us to cover your drug even if it is not on our formulary. Excluded drugs cannot be covered by a Part D plan unless coverage is through an enhanced plan that covers those excluded drugs.

• You may ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you may ask us to waive the limit and cover more. See Section 4 of your Evidence of Coverage to learn more about our additional coverage restrictions or limits on certain drugs.

• You may ask us to provide a higher level of coverage for your drug. If your drug is contained in our second or third tier, you may ask us to cover it at the cost-sharing amount that applies to drugs in the first tier instead. This would lower the co-payment amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug.

Generally, we will only approve your request for an exception if the alternative drugs included on the Plan formulary or the drug in the preferred tier would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

Your doctor must submit a statement supporting your exception request. In order to help us make a decision more quickly, the supporting medical information from your doctor should be sent to us with the exception request.

If we approve your exception request, our approval is valid for the remainder of the plan year, so long as your doctor continues to prescribe the drug for you and it continues to be safe and effective for treating your condition. If we deny your exception request, you may appeal our decision.

Note: If we approve your exception request for a non-formulary drug, you cannot request an exception to the co-payment or coinsurance amount we require you to pay for the drug.

Who May Ask for a Coverage Determination?

You, your prescribing physician, or someone you name may ask us for a coverage determination. The person you name would be your “appointed representative.” You may name a relative, friend, advocate, doctor, or anyone else to act for you. Other persons may already be authorized under state law to act for you. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to be your appointed representative. This statement must be sent to us at:

Positive Healthcare Partners
Attn: Member Services
4101 Ravenswood Ave., Suite 325
Fort Lauderdale, FL 33312

To learn how to name your appointed representative, you may call Member Services at
(888) 456-4715.

You also have the right to have a lawyer act for you. You may contact your own lawyer, or request the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify.