Coverage Determinations & Appeal Rights

A coverage determination (also known as a coverage decision) is a decision about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription is not covered under your plan, that is not a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage.

Here are examples of coverage decisions you can ask us to make about your Part D drugs:

You can ask us to make an exception, including:

• Asking us to cover a Part D drug that is not on the plan’s List of Covered Drugs
• Asking us to waive a restriction on the plan’s coverage for a drug (such as limits on the amount of the drug you can get)
• Asking us to pay a lower cost-sharing amount for a covered non-preferred drug

You can ask us whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on the plan’s List of Covered Drugs but we require you to get approval from us before we will cover it for you.)

You can ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment.

If you disagree with a coverage decision we have made, you can appeal our decision. For more information regarding the coverage determination process please reference Chapter 9, Section 6 in your Evidence of Coverage.