COVERAGE DETERMINATIONS

Understand how to request coverage exceptions, prior authorizations and more

Coverage Determinations

If you require a medication that is not on the EnvisionRxPlus formulary and you cannot use a formulary alternative, or if you require an exception to one of our utilization management rules or tiered cost-sharing, you have the right to request a coverage determination.

What is a Coverage Determination?

Any determination made by EnvisionRxPlus to provide or pay for a Part D drug that the enrollee believes may be covered by the plan (including a decision not to pay because the drug is not on the plan’s formulary, because the drug is determined not to be medically necessary, because the drug is furnished by an out of network pharmacy or because the Part D plan sponsor determines that the drug is otherwise excluded under section 1862(a) of the Act if applied to Medicare Part D).

  • Prior Authorization or other Utilization Management - decisions related to whether a member has, or has not, satisfied a prior authorization or other utilization management requirement (such as step therapy or quantity limits). Learn more about Prior Authorizations.
  • Tier Exception Requests - decisions concerning a higher level of coverage for your drug. If your drug is contained in our non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty Drug tier (tier 5).
  • A decision concerning an exception request involving a non-formulary drug.
  • A decision concerning an exception to a prior authorization or other utilization management requirement.
  • Reimbursement Requests - decisions concerning reimbursement for prescription drugs that you have already purchased.

What happens after I request a decision?

After receipt of a request for coverage determination, our team will review it and notify you or your authorized representative, and your prescribing physician (as appropriate) of our decision regarding your request for coverage determination as expeditiously as your health condition requires.

  • For standard requests we will advise of our decision no later than 72 hours from the receipt of the request, or, for an exception request, no later than 72 hours from receipt of the physician's supporting statement.
  • Regarding a request for reimbursement, no later than 14 days from receipt of the request.
  • For fast requests we will advise of our decision no later than 24 hours from the receipt of the request, or, for an exception request, no later than 24 hours from receipt of the physician's supporting statement.
    • For fast decisions requested by your doctor or by you with supporting information from your doctor indicating that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you a fast decision. If you ask for a fast initial decision without support from a doctor, we will decide if your medical condition requires a fast decision.
    • If we decide that your medical condition does not meet the requirements for a fast initial decision, we will send you a letter informing you that if you get a doctor’s support for a "fast" review, we will automatically give you a fast decision. You have the right to resubmit your request for an expedited coverage determination with your prescribing physician's support. The letter will also tell you how to file a "grievance" if you disagree with our decision to deny your request for a fast review. If we deny your request for a fast initial decision, we will instead give you a standard decision (within 72 hours).

If EnvisionRxPlus decides the coverage determination fully in your favor, we will:

  1. Attempt to contact you by phone
  2. Send a written approval notification to you and your prescribing physician
  3. Process the coverage determination, which will allow the pharmacy to process your prescription

For denials related to drug coverage, in whole or in part, we will send written notice of the determination and provide verbal notification. Your prescribing physician will also receive written notification if s/he provided a supporting statement. The denial notice will state the specific reason for the denial and contain all of the applicable Medicare appeals language. For denials related to reimbursement, EnvisionRxPlus will also send a written notice containing all of the applicable Medicare appeal language.

If we fail to make a coverage determination within the specified timeframe, it constitutes an adverse coverage determination. We will then send the request to the Independent Review Entity (IRE) designated by CMS within 24 hours of the expiration of adjudication timeframe and the IRE will issue a determination. You will be notified in writing by EnvisionRxPlus that your request was sent to the IRE.

An adverse coverage determination constitutes any unfavorable decision made by or on behalf of EnvisionRxPlus regarding coverage or payment for prescription drug benefits you believe you are entitled to receive. The following actions are considered adverse coverage determinations:

  • A decision not to provide or pay for a prescription drug. This includes:
    • Not to pay because the drug is not on the plan's formulary,
    • Not to pay because it has been determined that the drug is not medically necessary,
    • Not to pay because the drug is furnished by an out of network pharmacy or EnvisionRxPlus determines the drug is otherwise excluded under section 1862 (a) of the Act) that you believe should be covered by the plan.
    • The failure to provide a coverage determination in a timely manner when a delay would adversely affect your health.

If you disagree with a decision we have made, you have the right to appeal that decision.

Click to view any of the following plan documents:

To find out if your medication requires a prior authorization and to download necessary forms, search the formulary.

You can appoint a representative to act on your behalf for filing a coverage determination or appeal by providing us with a completed Appointment of Representative Form or visit the CMS Medicare website at www.cms.hhs.gov/MedPrescriptDrugApplGriev/13_Forms.asp. Please note by clicking on this link, you will be leaving the EnvisionRxPlus website.

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