Coverage Determination
Whenever you ask for a Part D prescription drug benefit, the first step is called "requesting a coverage determination." If your doctor or pharmacist tells you that a certain prescription drug is not covered, you must contact us if you want to request a coverage determination. When we make a coverage determination, we are making a decision whether or not we will provide or pay for a Part D drug and what your share of the cost is for the drug. You have the right to ask us for an "exception" which is a type of coverage determination, if you believe you need a drug that is not on our list of covered drugs (formulary) OR believe you should get a drug at a lower copayment. If you request an exception, your physician MUST provide a statement to support your request. This supporting statement may be oral or written.
You, your prescribing physician or your appointed representative may file your request for a coverage determination with our Member Services Department at 386-615-4022 or 1-877-615-4022 or by fax at 386-676-7149. From November 15 through March 1 the hours of operation are 7 days a week, 8 a.m. to 8 p.m. From March 2 through November 14 the hours of operation are Monday through Friday, 8 a.m. to 8 p.m. The hearing impaired may call TTY 1-877-260-8312.
HOW TO REQUEST A COVERAGE DETERMINATION?
You, your prescribing physician, or your appointed representative may check on the status of your coverage request by contacting our Member Services Department. If we deny your request (this is sometimes called an "adverse coverage determination"), you may "appeal" the decision.
The following are examples of coverage determination requests:
- You ask us to pay for a prescription drug you have received
- You ask for a Part D drug that is not on your plans list of covered drugs (called a "formulary"). This is a request for a "Formulary Exception."
- You ask for an exception to our utilization management tools such as: prior authorization, dosage limits, quantity limits, or step therapy requirements. Requesting an exception to a utilization management tool is a type of formulary exception.
- You ask for a "Non-Preferred" Part D drug at the "Preferred" cost sharing level. This is a request for a "tiering exception".
- You ask us to pay you back for the cost of a drug you bought at an out-of-network pharmacy.
To file your Part D Coverage Determination orally, please call FHCP's Member Services Department at 1-877-615-4022. From November 15 through March 1 of each year the hours of operation are 7 days a week, 8 a.m. to 8 p.m. From March 2 through November 14 of each year the hours of operation are Monday through Friday, 8 a.m. to 8 p.m. The hearing impaired may call TTY at 1-877-260-8312.
You may also submit your Part D Coverage Determination in writing to:
Florida Health Care Plans
Attn: Member Services
1340 Ridgewood Avenue
Holly Hill, FL 32117
Fax: 386-676-7149
Email: click here
To assist you, the member, in completing your request for a Part D Coverage Determination, please complete FHCP's Request for Medicare Prescription Drug Coverage Determination form and submit to Florida Health Care Plans as follows.To access the document(s) Adobe Reader® must be installed on your computer. If you do not have Adobe Reader ®, you can download it for free by clicking here.
WHO MAY REQUEST A COVERAGE DETERMINATION
You, your prescribing physician or someone you name may ask for a coverage determination. The person you name would be your "appointed representative." If you want someone to act for you who is not already authorized under State Law then you and that person must sign and date the Appointment of Representative form that gives the person legal permission to be your appointed representative. This Appointment of Representative form must be included with the coverage determination request.To access the document(s) Adobe Reader® must be installed on your computer. If you do not have Adobe Reader ®, you can download it for free by clicking here.
- Members of the Medvantage Rx & Rx Plus Plans please refer to Section 5 of your Evidence of Coverage for complete information regarding coverage determination.