Requesting an exception to coverage

How to request exceptions to what PriorityMedicare covers

This section is a summary of the more complete information in your PriorityMedicare^SM plan's Evidence of Coverage booklet (the links at the bottom of this page let you view this document online).

The process for asking for an exception to what is covered under your plan is different from what you should do if you're unhappy with our service or the service you receive from our network. To make a service complaint, go to the section on service complaints (grievances).

Examples of exceptions
If your doctor or pharmacist tells you that a certain drug or service is not covered and you believe it should be, you or your authorized representative can ask us to:

• Cover a drug that is not on our approved drug list. Generally, we'll only approve your request if the drugs on the approved drug list wouldn't be as effective in treating your condition, and/or if they would cause you more health problems.
• Give you an exception if the drug your doctor wants you to take first requires step therapy (trying other things first) or quantity limits.
• Give you an exception if the service your doctor wants you to have is not covered by your PriorityMedicare plan.

You will need a statement from your doctor supporting your request.

First, call Customer Service.
We may be able to save you a lot of paperwork if you call us first.

Next, request an "initial decision."

1. Ask your doctor to write a statement supporting your request. He or she should use a Coverage Determination Request Form (237KB PDF).
2. Call Customer Service to ask for an "initial coverage decision." You don't need to put your request in writing, but you can use the federal government's Coverage Determination Request Form if you wish.
3. Customer Service will explain how to submit the statement from your doctor and your request to us by fax or by mail.

Unless there are medical reasons for us to respond more quickly, we'll generally make a decision:

• Within 72 hours of your request for an exception to the drugs we cover
• Within 2 weeks of your request for an exception to the medical services covered by your plan

If you are granted an exception, it will usually be good for the rest of the calendar year.

If you aren't satisfied with the initial decision:
You can ask us to reconsider our initial decision not to make an exception. This request for us to reconsider a decision is called "filing an appeal." Go to instructions for filing an appeal.

Learn how to name an authorized representative to act for you.

What is covered by your plan?

For complete information about what's covered under your PriorityMedicare plan, refer to your plan's Evidence of Coverage booklet. Use the links below and then go to the page noted.

• Evidence of Coverage for PriorityMedicare Value^SM plan  see page 29
• Evidence of Coverage for PriorityMedicare^SM plan  see page 29
• Evidence of Coverage for PriorityMedicare Plus^SM plan  see page 29
• Evidence of Coverage for PriorityMedicare Rx^SM plan  see page 19

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