Coverage Determinations

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

• Receipt of, or payment for, a prescription drug that an enrollee believes may be covered;
• A tiering or formulary exception request (for more information about exceptions, click on the link to "Exceptions" located on the left hand side of this page);
• 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;
• A limit on the quantity (or dose) of a requested drug and the enrollee disagrees with the requirement or dosage limitation;
• 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; or
• A decision whether an enrollee has, or has not, satisfied a prior authorization or other utilization management requirement.

How to Request a Coverage Determination

An enrollee, an enrollee's prescriber, or an enrollee's representative may request a standard or expedited coverage determination by filing a request with the plan sponsor.  Standard or expedited requests for benefits may be made verbally or in writing.  Standard requests for payment must be made in writing, unless the plan sponsor accepts requests verbally.  Written requests may be made by using the Model Coverage Determination Request Form (see the link in the "Downloads" section below), 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 prescriber, or any other person.

For more information about exceptions, click on the link to "Exceptions" located on the left hand side of this page.

How a Plan Sponsor Processes Coverage Determination Requests

For requests for benefits that do not involve exceptions, a plan sponsor must provide notice of its decision within 24 hours after receiving an expedited request or 72 hours after receiving a standard request. The initial notice may be provided verbally so long as a written follow-up notice is mailed to the enrollee within 3 calendar days of the verbal notification. 

For requests for benefits that involve exceptions, the adjudication timeframes do not begin until the plan sponsor receives the supporting statement from the enrollee’s prescriber.  For more information, see the "Exceptions" page using the link on the left hand side navigation menu on this page.

For payment requests, including payment requests that involve exceptions, a plan sponsor must provide written notice of its decision (and make payment when appropriate) within 14 calendar days after receiving a request.  

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.

For more information about coverage determinations, see section 40, or, for appointing a representative, see section 20, in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance in the "Downloads" section below.

For a chart illustrating the prescription drug appeals process, click on the "Prescription Drug  Appeals Flow Chart" in the "Downloads" section below.