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Part D Coverage Determinations

(Also referred to as "coverage decision" for drugs")

What is Coverage Determination?

Coverage determination means that Care1st would be making a decision about whether prescription drugs are covered under your plan. Your benefits as a member of our plan include coverage for many prescription drugs. To be covered, the drug must be used for a medically accepted indication. (A "medically accepted indication" is a use of the drug that is either approved by the Food and Drug Administration or supported by certain reference books.

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 the Prescription drugs you are requesting. You, your doctor or your representative can do this by one of the options below.

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

If you want to ask us to pay you back for a drug please refer to the Organization Determination for Reimbursement

If you are requesting an exception, you must provide the "supporting statement". Your doctor or other prescriber must give us the medical reasons for the drug exception you are requesting. 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 follow up by faxing or mailing a written statement if necessary.

We must accept any written request, including a request submitted on the CMS Model Coverage Determination Request Form which is available below:

Step 2

We consider your request and we give you our answer.

Timeframes

Standard Coverage Decision.

In a standard coverage decision, we must give you our answer within 72 hours. Generally, this means within 72 hours after we receive your request. If you are requesting an exception, we will give you our answer within 72 hours after we receive your doctor’s statement supporting your request. We will give you our answer sooner if your health requires us to.

If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization.

If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 72 hours after we receive your request or doctor's statement supporting your request.

Fast coverage decision

If we are using the fast deadlines, we must give you our answer within 24 hours.

Generally, this means within 24 hours after we receive your request. If you are requesting an exception, we will give you our answer within 24 hours after we receive your doctor's statement supporting your request. We will give you our answer sooner if your health requires us to.

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.

If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 24 hours after we receive your request or doctor’s statement supporting your request.


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.

Step 3

If we say no, you have the right to request an appeal. Requesting an appeal means asking us to reconsider – and possibly change – the decision we made.

For information on appeals, please go to our Appeals Process page.

You may also see information on Coverage Determination in Chapter 9, Sections 1-10 of the Evidence of Coverage.

You may submit feedback/complaints about your Medicare Advantage health 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.