Medicare Prescription Coverage Determinations and Exceptions
Learn more about Medicare coverage determinations and how they can apply to your prescription drugs.
Understanding Medicare Coverage Determinations
A coverage determination is a process that helps make sure the medicine you receive is appropriate, effective, and covered by your health plan before you get it. Coverage determinations apply to select prescription drugs.
You may also hear coverage determination called prior authorization or coverage re-determination.
What are the different types of coverage determinations and exceptions for prescription drugs?
The most common are:
Prior authorization (PA): An approval to get certain medications, procedures or treatments.
Step therapy (ST): Requires you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed.
Quantity limit: Limits the amount of medication we may cover over a specific period to help ensure quality and safety.
Formulary Exception: Allows you to get a drug that is not on HealthSpring’s list of covered drugs, called a formulary.
Tiering Exception: Approval to receive or get a lower co-payment for a drug that sits on a higher, more expensive tier
Why Coverage Determinations Are Important
There are many reasons why coverage determinations are important, including:
They check if the care is essential: You might hear this called “medical necessity.” Reviewers check your doctor’s notes and records to make sure the recommended care is right for your needs and is a standard, accepted care option.
They take steps to help control costs: Reviewers check if there are other care options that might work at a lower cost or be more cost-efficient.
They review any risks: Reviewers look into your medical history, checking that there aren’t any harmful drug interactions or that you’re not at a higher risk of complications.
It helps prevent fraud, waste or abuse: Coverage determinations are a checkpoint to make sure you and your health care benefits are not misused.
During the process, HealthSpring, or a company on behalf of HealthSpring, will review the requested medication to see if it is medically necessary.
How Do I Know If I Need a Coverage Determination?
There are many ways you can review your plan coverage to find out if a review is required:
Refer to your plan formulary (drug list): If your medication requires a coverage review, it will be notated in this plan document
Log in to myHealthSpring: In the member portal, you can review your coverage and costs, including any plan rules or limitations
Call customer service: Call the number on your HealthSpring member ID card for help
Ask your provider: In most cases, your doctor or treating provider will know if a coverage determination is needed and will submit the request for you
How to Request a Coverage Determination
You, your doctor or prescriber, or an authorized representative may request a coverage determination by phone, mail, fax, or online.
To find plan restrictions or requirements for your plan, log in to your member portal, myHealthSpring.
Online:
Request Prescription Drug Coverage Determination
By Phone:
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 Member 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: 1-866-845-7267
What If My Medication Is Not Covered?
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.
What Happens If My Request for Coverage Is Denied?
If your coverage determination request is denied, you will receive a letter from HealthSpring with more information. The letter will outline your options, including how to submit an appeal. You can also discuss a change in care with your doctor. If you choose to get the drug after your coverage determination request is denied, you will be responsible for the costs not paid under your coverage.
To learn more about your right to appeal, visit our Medicare Appeals Process page.
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 Member 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.
How Long Does a Coverage Determination Take?
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 Member 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.