A coverage determination is any decision made by the Part D plan sponsor regarding:

1.  Receipt of, or payment for, a prescription drug that an enrollee believes may be covered;

2.  A tiering or formulary exception request;

3.  The amount that the plan sponsor requires an enrollee to pay for a Part D prescription drug and the enrollee disagrees with the plan sponsor;

4.  A limit on the quantity (or dose) of a requested drug and the enrollee disagrees with the requirement or dosage limitation;

5.  A requirement that an enrollee try another drug before the plan sponsor will pay for the requested drug and the enrollee disagrees with the requirement; and

6.  A decision whether an enrollee has, or has not, satisfied a prior authorization or other utilization management requirement.

An enrollee, an enrollee’s physician, or an enrollee’s appointed representative may request a standard or expedited coverage determination by filing a request with the plan sponsor.

For more information about appointing a representative, see section 10.4 in Chapter 18 of the Prescription Drug Benefit Manual.
How to Request a Coverage Determination

Expedited requests may be filed orally or in writing.

Standard requests must be filed in writing, unless the plan sponsor accepts requests orally.

Written requests may be made by using the Model Coverage Determination Request Form, a coverage determination request form developed by a plan sponsor or other entity, or any other written document prepared by the enrollee, the enrollee’s physician, or any other person.

Physicians may also submit written requests on the Model Coverage Determination Request Form for Physicians.  This form can be used to request a coverage determination or exception, submit a statement in support of an exceptions request, or attempt to satisfy a utilization management requirement.
How a Plan Sponsor Processes Coverage Determination Requests

For coverage determinations that do not involve exceptions requests, a plan sponsor must notify an enrollee of its coverage determination within 24 hours after receiving an expedited request or 72 hours after receiving a standard request.

For coverage determinations that involve exceptions, the adjudication timeframes do not begin until the enrollee’s prescribing physician submits his or her supporting statement to the plan sponsor.
If the plan sponsor’s coverage determination is unfavorable, the decision will contain the information needed to file a request for redetermination with the plan sponsor.