Medicare Coverage Decisions and Exceptions
Learn more about Medicare coverage decisions and exceptions such as requirements, forms and contact information.
Exceptions and Coverage Decisions
You may ask for coverage for a medication that is not covered by your plan or has coverage limitations. In this case, you, your doctor, your prescriber or someone who is acting on your behalf can ask for an exception to our rules (also known as a coverage decision or coverage determination).
Here are some examples of exceptions:
- You ask for a drug that is not on your plan's list of covered drugs (also called a “formulary”). This is a request for a “formulary exception.”
- You ask for an exception to our plan's utilization management tools—such as dosage limits, quantity limits, prior authorization requirements or step therapy requirements. Asking for an exception to a utilization management tool is a type of formulary exception.
- You ask for a non-preferred drug at the preferred cost-sharing level. This is a request for a “tiering exception."
- You ask us to pay our part of a covered drug you have purchased at an out-of-network pharmacy or other times you have paid the full price for a covered drug under special circumstances.
Check your plan's Complete Drug List Formulary to see if your requested medication needs a coverage determination.
Fast Coverage Decisions (Expedited Coverage Determination)
You can ask us to give you a “fast coverage decision.” When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard coverage decision means we will give you an answer within 72 hours after we get your doctor’s statement. A fast coverage decision means we will answer within 24 hours after we get your doctor’s statement.
If your doctor or other prescriber tells us that you need a “fast coverage decision” for your health, we will automatically agree to give you a fast coverage decision.
Who Can Request a Coverage Determination
You, your prescribing physician, or someone you name can ask us for a coverage determination. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor or someone else to act for you. If you want someone to act for you, then you and that person must sign and date the Appointment of Representative form (you can find this on the Customer Forms page). This form gives the person legal permission to act as your representative. This statement must be faxed or mailed to us at the designated number or address. The Appointment of Representative form does not have to be filled out if a physician is submitting an exception or coverage determination request.
Your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception. For more information about exception criteria, you can reach us at:
8 a.m. – 8 p.m., Monday – Saturday
How to Request a Coverage Determination
Online Forms
Request Prescription Drug Coverage Determination
By Phone
8 a.m. – 8 p.m., Monday – Saturday
By Mail or Fax
To ask for an exception, fill out and submit a Coverage Determination Request form. (You can find these forms on the Customer Forms). Once you’ve filled it out, mail or fax to:
Express Scripts
Attn: HealthSpring Medicare Reviews
P.O. Box 66571
St. Louis, MO 63166-6571
Fax:
Coverage Decision Deadlines
For a “Standard Coverage Decision”
For standard coverage decisions, HealthSpring must give you our answer within 72 hours. Generally, this means within 72 hours after we get the request. If you are asking for an exception, we will give you our answer within 72 hours after we get your doctor’s statement supporting your request. If we do not meet this deadline, we must forward your request to be reviewed by an independent organization.
If we approve your request for coverage, we must give you the coverage we have agreed to provide within 72 hours after receipt of your request or doctor’s statement supporting your request.
If our answer is yes to part or all of what you asked for, we must give you the coverage we have agreed to provide within 24 hours after receipt of your request or doctor’s statement supporting your request. If our answer is no to part or all of what you asked for, we will send you a written statement.
For a “Fast Coverage Decision”
For fast coverage decisions, HealthSpring must give you our answer within 24 hours. Generally, this means within 24 hours after we get the request. If you are asking for an exception, we will give you our answer within 24 hours after we get your doctor’s statement supporting your request. We will give you our answer sooner if your health depends on it. If we do not meet this deadline, we must forward your request to be reviewed by an independent outside organization.
If our answer is yes to part or all of what you asked for, we must give you the coverage we have agreed to provide within 24 hours after receipt of your request or doctor’s statement supporting your request.
If our answer is no to part or all of what you asked for, we will send you a written statement that explains why we said no. We will also tell you how to appeal.
More Information
To get more coverage determination information or to find forms, go to Customer Forms. To learn more about the aggregate number of HealthSpring Medicare grievances, appeals and exceptions or the financial condition of HealthSpring Medicare, please contact us.
You have the right to file a complaint:
If you have a complaint, you can send your feedback straight to Medicare using the Medicare Complaint form.