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Coverage Determination and Redetermination

Requesting Exception | Coverage Determinations | Coverage Redeterminations | Drug Coverage | Questions | Forms

How do I request an exception to the
Health Choice Generations HMO Formulary?

You can ask Health Choice Generations to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

  • You can ask us to cover your drug even if it is not on our formulary.
  • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Health Choice Generations HMO limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
  • You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our highest tier subject to the tiering exceptions process tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the lowest tier subject to the tiering exceptions process tier instead.

This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug.

If you are requesting an exception, you must provide a statement from your doctor. Your doctor or other prescriber must give us the medical reasons for the drug exception you are requesting. Your doctor can mail or fax the statement to our plan. Or your doctor can tell us on the phone and then follow up by faxing or mailing the signed statement.

The Physician Medicare form can be found at:
http://www.cms.hhs.gov/MedPrescriptDrugApplGriev/Downloads/
PhysicianCoverageDeterminationRequestForm.pdf

The statement can be faxed or mailed to:

Health Choice Generations HMO
Attn: Pharmacy Prior Authorizations
410 N 44th Street, Suite 900
Phoenix, AZ 85008

Fax: 1-888-291-4542

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Prescription Drug Decisions
Coverage Determinations

If you would like Health Choice Generations to make a decision on a Part D drug, such as a formulary exception, you and your doctor may complete a Coverage Determination Request Form. When Health Choice Generations makes a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug. The decision by a pharmacist not to fill a prescription is not considered a denial by Health Choice Generations.

Coverage determinations include:

  • Prior authorizations by Health Choice Generations before a pharmacy may dispense certain drugs,
  • Limits set by Health Choice Generations on the quantity (amount) of certain drugs that can be dispensed,
  • A decision to pay a claim for a drug you paid for,
  • A decision whether a prescribed drug is medically necessary, appropriate, or used for an FDA-approved indication, and
  • A request for an "exception" to the formulary as discussed below.
You, your authorized representative, or your prescribing physician may request a coverage determination. Decisions are made within 72 hours, unless your health is in jeopardy and a request is made for a fast-track decision. We verify the need for a fast-track decision and then make the coverage determination as quickly as possible - within 24 hours of the request.

Note: You cannot request a Re-determination/Appeal if we have not issued a Coverage Determination.

If coverage is denied, you will be notified and receive a written explanation with a notice of appeal rights. If your request for a fast-track decision is denied and you disagree, you may file an expedited grievance. You are always notified of our decisions.

To request an expedited review, please call 1-800-656-8991. TTY/TTD users call 1-800-842-4681.

You have the option of submitting your request in writing. You may mail or fax your written request for a coverage determination to:

Health Choice Generations HMO
Attn: Pharmacy Prior Authorizations
410 N 44th Street, Suite 900
Phoenix, AZ 85008

Fax: 1-888-291-4542

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Prescription Drug Decisions
Coverage Re-determinations

If we deny part or all of the coverage determination and you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug, you may ask us to reconsider our decision. This is called an "appeal" or "request for re-determination".

Note: You cannot request a Re-determination/Appeal if we have not issued a Coverage Determination.

How you make your appeal depends on whether you are requesting reimbursement for a Part D drug you already received and paid for, OR authorization of a Part D benefit (that is, a Part D drug that you have not yet received).

If your appeal concerns a decision we made about authorizing a Part D benefit that you have not yet received, then you and/or your doctor will first need to decide whether you need a redetermination. The procedures for deciding on a standard or fast redetermination are the same as those described for a standard or fast coverage determination.

Please be assured, when we receive your request to reconsider the coverage determination, we give the request to healthcare professionals at our organization who were not involved in making the original coverage determination. This helps ensure that we give your request a fresh look.

How to Request a Redetermination

You must make your redetermination (appeal) request to Health Choice Generations within 60 calendar days from the notice of the initial coverage determination. An expedited request may be made orally or in writing. A standard request may be made orally or in writing. You may choose to complete the redetermination form in the Form section on this page or you may submit your signed request in another format.

To request an expedited redetermination, please call 1-800-656-8991. TTY/TTD users call 1-800-842-4681.

You have the option of submitting your request in writing. You may mail or fax your written request for a coverage redetermination to:

Health Choice Generations HMO
Attn: Pharmacy Prior Authorizations
410 N 44th Street, Suite 900
Phoenix, AZ 85008

Fax: 1-888-291-4542

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Medicare Prescription Drug Coverage and Your Rights

You have the right to get a written explanation from Health Choice Generations if:
  • Your doctor or pharmacist tells you that Health Choice Generations will not cover a prescription drug in the amount or form prescribed by your doctor.
  • You are asked to pay a different cost-sharing amount than you think you are required to pay for a prescription drug.
Health Choice Generations written explanation will give you the specific reasons why the prescription drug is not covered and will explain how to request an appeal if you disagree with the drug plan's decision.

You also have the right to ask Health Choice Generations for an exception if:

  • You believe you need a drug that is not on your drug plan's list of covered drugs. The list of covered drugs is called a "formulary;" or
  • You believe you should get a drug you need at a lower cost-sharing amount.
What you need to do:
  • Contact Health Choice Generations to ask for a written explanation about why a prescription is not covered, or to ask for an exception if you believe you need a drug that is not on your drug plan's formulary, or believe you should get a drug you need at a lower cost-sharing amount.
  • Refer to the Summary of Benefits you received from Health Choice Generations or call Member Services at 1-800-656-8991
  • When you contact Health Choice Generations, be ready to tell them:
    1. The name of the prescription drug(s) that you believe you need.
    2. The name of the pharmacy or physician who told you that the prescription drug(s) is not covered.
    3. The date you were told that the prescription drug(s) is not covered.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0975. The time required to distribute this information collection once it has been completed is one minute per response, including the time to select the preprinted form, and hand it to the enrollee. If you have any comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

No. CMS-10147 APPROVED OMB #0938-0975

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Questions?

You can find detailed information regarding the Grievance and Appeals processes in your Evidence of Coverage booklet.

You may also call Member Services at 1-800-656-8991, 8 am - 8 pm, 7 days a week for assistance with problem solving related to your Part D benefits or for questions about processes or appeal status (TTY users call 1-800-842-4681).

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Forms

Coverage Determination Request Form for Physicians:
http://www.cms.hhs.gov/MedPrescriptDrugApplGriev/Downloads/
PhysicianCoverageDeterminationRequestForm.pdf

An enrollee, or the appointed representative, or the prescribing physician may use this model form to request a coverage determination from the plan.
http://www.cms.hhs.gov/MedPrescriptDrugApplGriev/Downloads/
ModelCoverageDeterminationRequestForm.pdf

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