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: Medicare Part D Coverage Determination and Appeal Request Form.
Standard requests have a 72-hour timeframe to be resolved. This begins once the prescribing physician or prescriber provides supporting documentation.
Request for Prescription Drug Coverage Determination
Expedited requests have a 24-hour timeframe to be resolved. This begins once the prescribing physician or prescriber provides supporting documentation.
Request for Redetermination of Medicare Prescription Drug Denial
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 an Appeal?
If we deny coverage or payment for a prescription that you think we should cover or pay for, you may request an appeal. You can ask us to “expedite” or give you a quick decision if we have denied coverage (but not if your appeal is related to payment for services you already received).
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.
