Asking for a Medicare coverage decision

This section is a summary of the information in your Priority Health Medicare plan's "Evidence of Coverage" booklet.
View your plan documents online.

First, call Customer Service.

We may be able to resolve your concern over the phone, 8 a.m. to 8 p.m., 7 days a week. Call us toll free at 888 389-6648. TTY users should call 711.

Next, request a "coverage decision."

1. Making your request
   
   To request a coverage decision for a medical service or to go to a doctor or hospital outside the Priority Health Medicare network, you can call the number above or write to us at:

   Health Management Department, MS-1255
   Priority Health Medicare
   1231 East Beltline Ave. NE
   Grand Rapids, MI  49525
   

   To request drug coverage decisions, use a Medicare Part D Coverage Determination Request Form (257KB PDF) to ask Priority Health to:

• Make an exception and cover a drug that is not on the formulary
• Ask for authorization for a drug your doctor has prescribed, if the drug requires prior authorization
• Ask to be excepted from the requirements that you try another drug first (step therapy requirements)
• Request an exception to the quantity limit on a drug
• Ask to be reimbursed for a covered precription drug you paid for out of your pocket
• Ask to keep paying a lower tier copayment, if your drug has been moved to a higher tier
• Ask to pay a lower tier copayment for the drug your prescriber prescribed, if that drug's copayment is higher than other drugs that treat your condition

Note: If you are asking for a formulary or copayment exception, you must have your doctor fill out a supporting statement (on page 3 of the form) explaining why you should receive an exception.

2. When you'll hear from us: Unless there are medical reasons for us to respond more quickly, we'll generally make a decision:
• Within 2 weeks of your request for a medical service coverage decision
• Within 72 hours of your request for a drug coverage decision
  
3. If our coverage decision is in your favor: We must authorize the drug or medical service we agreed to provide. For prescription drug exceptions to the formulary, our approval is usually good for the rest of the calendar year.

Filing an appeal

If you aren't satisfied with the coverage decision we make, you can ask us to reconsider. This is called "filing an appeal."
Go to instructions for filing an appeal.

What is covered by your plan?

For complete information about what's covered by your Priority Health Medicare plan and how to ask for an exception to coverage or file a complaint (grievance), refer to your plan's "Evidence of Coverage" booklet. 
Go to your Medicare plan information to find your booklet online.