Coverage Determinations & Appeal Rights

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 can ask us to make about your Part D drugs:

You can ask us to make an exception, including:

  • Asking us to cover a Part D drug that is not on the plan’s List of Covered Drugs
  • Asking us to waive a restriction on the plan’s coverage for a drug (such as limits on the amount of the drug you can get)
  • Asking us to pay a lower cost-sharing amount for a covered non-preferred drug

You can 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 can 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 Chapter 9, Section 6 in your Evidence of Coverage.

If mailing a request for a coverage decision to Senior Care Plus, please address the request to:

PO Box 2975
Mission, KS 66201

You may also fax completed requests to OptumRx at 1-844-403-1028.

If you would like to print the forms yourself, please click the ‘Coverage Determination Request Form’.  Please complete the form and address it to the appropriate individual. If mailing to OptumRx, please address the form to: OptumRx, PO Box 2975 Mission, KS 66201. You may also fax completed forms to OptumRx at 1-844-403-1028.



Because your Medicare drug plan has denied coverage of, or payment for, a prescription drug you requested, you have the right to ask for a redetermination (appeal). You may use the form below to request a redetermination of our initial decision. You have 60 days from the date of the plan’s initial denial notice to ask for a redetermination. 

Please complete the Appeals – Request for Reconsideration of Medicare Prescription Drug Denial Form and mail or fax it to:

Address: Senior Care Plus
10315 Professional Circle,
Reno, NV 89521

Fax: 775-982-3745


You may ask for a redetermination by calling 775-982-3112 or your prescriber may ask us on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative.

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