Part D Coverage and Determination Appeals

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Our Part D Benefit

You can get the request form to begin the process for a prescription drug to be covered, that is not already covered. Your physician will need to fill out the Part D Coverage Determination form.

You can find the form here: Request for Prescription Drug Coverage Determination

Standard requests have a 72-hour timeframe to be resolved. This begins once the prescribing physician or prescriber provides supporting documentation.

Expedited requests have a 24-hour timeframe to be resolved. This begins once the prescribing physician or prescriber provides supporting documentation.

 

 

What is Coverage Determination?

You or your physician requests a drug from El Paso Health Advantage Dual SNP (HMO D-SNP), a drug that is not on the formulary. El Paso Health Advantage Dual SNP (HMO SNP) works with its Pharmacy Benefits Manager, Navitus Health Solutions, to review Coverage Determinations. Your request will be reviewed and a coverage decision will be provided to you and your physician. You may ask for an expedited coverage decision if you feel you need a fast decision.

 

What is a Coverage Redetermination/Appeal? 

Because we denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination. This form may be sent to us by mail or fax.

You can ask us to “expedite” or give you a quick decision if we have denied coverage and you believe using the standard deadlines could cause serious harm to your health or hurt your ability to function. Request for Redetermination of Medicare Prescription Drug Denial

 

If you need assistance, call Member Services at 1-833-742-3125 (TTY 1-855-532-3740), from October 1 to March 31, 8:00 am to 8:00 pm, 7 days a week and April 1 through September 30, Monday through Friday, 8:00 am to 8:00 pm Mountain Time.

 

H3407_website CMS Accepted 10/09/2019