A coverage determination (also known as a coverage decision) is a decision about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription is not covered under your plan, that is not a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage.
Here are examples of coverage decisions you ask us to make about your Part D drugs:
You ask us to make an exception, including:
You ask us whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on the plan’s List of Covered Drugs but we require you to get approval from us before we will cover it for you.)
You ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment.
If you disagree with a coverage decision we have made, you can appeal our decision. For more information regarding the coverage determination process please reference the below sections in your Evidence of Coverage.
|Value Rx (HMO)||Chapter 9||Sections 6|
|Value Rx Enhanced (HMO)||Chapter 9||Sections 6|
|Value Rx Select (HMO)||Chapter 9||Sections 6|
|Freedom Rx (PPO)||Chapter 9||Sections 6|
|Freedom Rx Select (PPO)||Chapter 9||Sections 6|
|Freedom Rx Enhanced (PPO)||Chapter 9||Sections 6|
We encourage you to contact Senior Care Plus if you have any questions or concerns regarding coverage determinations. Please call Customer Service at 775-982-3112 or toll-free at 888-775-7003, Monday–Sunday 7:00 a.m. to 8:00 p.m PST. TTY users should call the State Relay Service number at 711.
If you would like to print the forms yourself, please use the attachments below. Please complete the forms and address them to the appropriate individual. If mailing to Senior Care Plus, please address the form to: Senior Care Plus, 10315 Professional Circle Reno, NV 89521. You may also fax completed forms to Senior Care Plus at 775-982-3743.
Request for Medicare Prescription Drug Coverage Determination Form
If an existing member would like to request a prescription drug coverage determination regarding a prior authorization, quantity limit exception, step therapy exception, formulary exception, or a tiering exception, the member would complete the form and submit it to Senior Care Plus with a physician’s supporting statement.
Material ID: Y0039_2019_SCPWebsite_M (CMS Accepted) Last Updated 10/08/2018