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Part D Coverage Determinations
(also referred to as "coverage decision" for drugs)

What is Coverage Determination?

Coverage determination means that Cal MediConnect would be making a decision about whether prescription drugs are covered under your plan. The legal term for a coverage decision about your Part D drugs is "coverage determination." Coverage determination forms are used to ask for a coverage decision about a drug.

Do you want to find out whether we will cover a certain drug? If your health requires a quick response, you must ask us to make a “fast coverage decision.” You cannot ask for a fast coverage decision if you are asking us to pay you back for a drug you already bought.

Here is the step-by-step process:

Step 1

You ask our plan to make a coverage decision on thePrescription drugs you are requesting. You, your doctor or your representative can do this by one of the options below.

You may utilize the forms below to send us your request:

Form for Members: Medicare Prescription Drug Coverage Determination Form

Form for Providers: Care1st Prescription Drug Prior Authorization Request Form

For expedited requests, please call or fax using the contact numbers above.

Requesting exception: If you are requesting an exception, provide the "supporting statement." Your doctor or other prescriber must give us the medical reasons for the drug exception. We call this the “supporting statement.” Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone and then fax or mail a statement.

Step 2

We consider your request and give you our answer.

Timeframes

Standard coverage decision (for payment for a drug already purchased)

We must give you our answer within 14 calendar days after we get your request.

If we do not meet this deadline, we will send your request to Level 2 of the appeals process. At level 2, an Independent Review Entity will review the decision.

If our answer is Yes to part or all of what you asked for, we will make payment to you within 14 calendar days

Standard coverage decision (for a drug you have not yet received)

If we are using the standard deadlines, we must give you our answer within 72 hours after we get your request or, if you are asking for an exception, after we get your doctor’s or prescriber’s supporting statement. We will give you our answer sooner if your health requires it. If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. At Level 2, an Independent Review Entity will review the decision.

If our answer is Yes to part or all of what you asked for, we must approve or give the coverage within 72 hours after we get your request or, if you are asking for an exception, within 72 hours after we get your doctor’s or prescriber’s supporting statement.

Fast Coverage decision

If your health requires it, ask us to give you a "fast coverage decision." Fast coverage decision means we will give you an answer within 24 hours.

To get a fast coverage decision, you must meet two requirements:

  1. You can get a fast coverage decision only if you are asking for a drug you have not yet received. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.)
  2. You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.

Note: If your doctor or other prescriber tells us that your health requires a "fast coverage decision," we will automatically agree to give you a fast coverage decision, and the letter will tell you that.

If you ask for a fast coverage decision on your own (without your doctor’s or other Prescriber’s support), we will decide whether you get a fast coverage decision

  • If we decide to give you a standard decision, we will send you a letter telling you that. The letter will tell you how to make a complaint about our decision to give you a standard decision. You can file a "fast complaint" and get a decision within 24 hours.
  • If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will send you a letter that says so (and we will use the standard deadlines instead).
  • If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. At Level 2, an outside independent organization will review your request and our decision.
    If our answer is Yes to part or all of what you asked for, we must give you the coverage within 24 hours after we get your request or your doctor’s or prescriber’s statement supporting your request.

Step 3

If we say No to your coverage request, You can decide if you want to make an Appeal.

If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No. This statement will also explain how you can appeal our decision. For information on appeals, please go Appeals Process.

Also please refer to the Evidence of Coverage (EOC) Chapter 9 section 6.5, for more information.

If you have questions or need any assistance, please contact us at:

Members:

For all inquiries:
Care1st Cal MediConnect Plan Member Services
1-855-905-3825 (TTY: 711)

Physicians:

Appeals and Grievance Inquiries:
Care1st Member Services
1-855-905-3825 (TTY: 711)

Pharmacy Inquiries:

1-877-RXCARE1 (1-877-792-2731)

UM Inquiries:

1-800-468-9935

Aggregate Numbers :

How to Obtain an Aggregate Number of Grievances, Appeals and Exceptions Filed with Care1st Health Plan
To obtain an aggregate number of Care1st Health Plan's grievances, appeals and exceptions, please call Care1st Cal MediConnect Plan Member Services at 1-855-905-3825 (TTY: 711) from 8:00 a.m. to 8:00 p.m., seven days a week.

You may mail your form to:

Care1st Health Plan
Care1st Member Services (Coverage Decisions)
601 Potrero Grande Dr
Monterey Park, CA 91755

Or you can fax it to us at: (323) 889-6254 or (866) 712-2731

You may submit feedback/ complaints about your Cal MediConnect Plan directly to Medicare. By clicking on this link you will be leaving the Care1st Health Plan website and will be directed to the CMS Model Electronic Complaint Form.