Prescription drug coverage determinations
You have the right to request a coverage determination, including the rights to:
- request an exception,
- request prior authorization, step therapy and/or quantity limits approval, or
- get a non-preferred drug at a better out-of-pocket cost
Initial coverage determination is the process we use to decide whether we will cover the Part D drug based on one or more of the following factors and what the cost-sharing amounts will be:
- medical necessity;
- drugs not on the formulary;
- drugs provided by an out-of-network pharmacy;
- drugs that are benefit exclusions; and
- drugs requested as exceptions.
You may call our member services at 1-800-224-2273 (TTY users: 1-800-842-9710) between 8:00 a.m. and 8:00 p.m. seven days a week. Or you can use the prescription drug coverage determination (Y0026_126501_C NM) form. (solicitud de determinacion de cobertura de medicamentos de receta de Medicare)
You can submit your request for a prescription drug coverage determination to us in one of the following ways:
Attn: Pharmacy Services
55 Water Street
New York, NY 10041
An exception is a type of coverage determination. You may ask for an exception if you need a drug that is not on our list of covered drugs. You may also ask for an exception to rules, such as a limit on the quantity of a drug.
If you think you need an exception, contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision.
Remember, you can check to see if your drug is on our drug list (formulary) by using the Price-a-drug tool.
If your medication is not included in the formulary, you should contact us to ask if your medication is covered by your benefit. If you learn that ConnectiCare does not cover your drug, you have two options:
- You can ask member services for a list of similar drugs that we cover. Then show the list to your doctor and ask for a prescription for a similar drug that we cover.
- Or, you can ask us to make a prescription drug coverage determination (solicitud de determinacion de cobertura de medicamentos de receta de Medicare).
Last Update 11/26/2018