Members Resources
Find tools, information, and other resources to help you get the most out of your benefits.
Coverage Determination
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 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
What is an exception?
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 another prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request.
Who can request a coverage determination / exception?
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.
When can a coverage determination / exception be requestes?
A coverage determination may be requested for any of the following:
- Covering a Part D drug for you that is not on our 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 exception if you or your prescriber believe that a coverage rule (such as 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 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.
Important things to know about asking for exceptions
Your doctor or other prescribers 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 prescribers 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”.
Important things to know about asking for exceptions
To request a Medicare Prescription Drug Redetermination (Appeals) please call
Express Scripts at 1-800-204-0016
You can also mail to:
Express Scripts
Appeals: ATTN: Medicare Part D
P.O. Box 14718
Lexington, KY 40512-4718
Or Fax: 1-877-852-4070
Your provider may also request an exception or expedited exception by contacting the
Pharmacy Help Desk at 1-800-922-1577 (TTY 711) 24 hours a day, and 7 days a
week.
Our plan has seventy-two (72) hours (for a standard request) or twenty-four (24) hours
for an expedited request) from the date it gets your request to notify you of its
decision.