A coverage determination is a decision we make about your drug benefits and coverage, or about the amount we’ll pay for your drugs. You, your appointed representative, or your doctor or other prescriber have a right to ask us to make a coverage determination.
Types of coverage determinations
Request an Exception
This includes prescription drugs that are not on our Drug List (formulary) or are on the Drug List with limitations or restrictions. You can ask us to:
- Cover a drug even if it is not on our Drug List (formulary). If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
- Cover a drug on our Drug List at a lower cost-sharing level if the drug is not on the specialty tier. If approved, this would lower the amount you must pay for the drug.
- Waive coverage restrictions or limitations on your drug. For example, for certain drugs, Priority Health Medicare limits 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 a greater amount.
- Cover a drug on our Drug List that may have prior authorization criteria, or the requirement to try another drug first.
For exception requests, contact the Customer Care team by phone, send a message by logging into your member portal, or use a Medicare Part D coverage determination request form (PDF) to ask for a coverage decision.
Supporting statements from your doctor
- If you are asking for a formulary, utilization management (prior authorization, step therapy, or quantity limit) or drug tier exception, you must have your doctor submit a supporting statement (see form) explaining the medical reasons why you should receive an exception. Your doctor may submit their supporting statement over the phone or in writing.
When you’ll hear from us
- For standard coverage decisions, after we get a supporting statement from your doctor or other prescriber, we must make a decision within 72 hours of receipt of your request.
- When your request to expedite is granted, after we get a supporting statement from your doctor or other prescriber, we must give you our decision within 24 hours. To get a fast coverage decision, you must meet 2 requirements:
- You may only ask for coverage for a Part D drug that you have not received already
- 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 regain function.
Request us to cover a Part B medical drug
These include drugs you wouldn't usually give to yourself–like those you get at a doctor's office or at an outpatient infusion center. How to request coverage for Part B medical drugs, learn more .
Request for payment
This is for a Part D drug that you’ve paid for out-of-pocket and believe should be covered, also known as filing a claim or requesting reimbursement.
For Part D drug payment requests, send us a request in writing within three years of the date you got the drug. To make sure you’re giving us all the information we need to make a decision, you can use the Prescription expense reimbursement form (PDF) to make your request for payment.
When you’ll hear from us
- We must make a decision within 14 calendar days of receipt of your request.
If you disagree with our decision
You, your appointed representative, or your prescriber can ask us to reconsider if you are not satisfied with our coverage decision. This is called “filing an appeal.” Learn how.
Appointment of Representative
If you want someone else, like a family member or friend, to act on your behalf, you can sign a form that makes the person your official “authorized representative.” Learn how.