Coverage Determinations and Redeterminations for Drugs
What is a coverage determination?
A coverage determination is a choice IlliniCare Health makes on whether a drug prescribed for you is covered by the plan. Coverage determinations are also called coverage decisions.
What is an exception?
If a drug is not covered in the way you would like, you can ask us to make an “exception.” An exception is a type of coverage determination. Similar to other types of coverage determinations, if we turn down your request for an exception, you can appeal our decision. When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request.
Asking for a coverage determination or exception
Refer to your Member Handbook and go to Chapter 9 for more information on requesting a formulary exception. You, your physician, or your appointed representative may file a coverage determination, including an exception, by:
Phone: 1-866-399-0928 (TTY: 711)
Please see below for the Medicare Prescription Drug Coverage Determination Request Form. You cannot use this form for Medicare non-covered drugs: fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over the counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).
- Coverage Determination Request Form - English (PDF)
- Determinación de Cobertura de Medicamentos Formulario - Español (PDF)
- Request for Redetermination Form - English (PDF)
- Solicitud de formulario de redeterminación - Español (PDF)
If you have any questions, call Member Services at 1-877-941-0482. Hours are 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711.
Last Updated: 02/08/2018
A coverage determination is a decision about whether a drug prescribed for you will be covered by us and the amount you’ll need to pay, if any. If a drug is not covered or there are restrictions or limits on a drug, you may request a coverage determination.
You can ask us to cover:
- a drug that is not on our List of Drugs (Formulary).
- a drug that requires prior approval.
- a drug at a lower cost sharing tier.
- a higher quantity or dose of a drug.
You, your representative, or your doctor may submit a coverage determination request by fax, mail or phone. You must include your doctor’s statement explaining why your drug is necessary for your condition. Within 72 hours after we receive your doctor’s statement, we must make our decision and respond. If we deny your request you can appeal our decision. Information on how to file an appeal will be included in the denial notice.
Generally, we will approve your request only if the alternative drug is on our list of drugs, or if a lower cost-sharing drug or added restrictions don’t treat your condition as well. The contact information is listed below. You also can contact Member Services.
You may use this form to submit your request:
You can submit the Coverage Determination form through our secure online portal.
Doctors and Other Prescribers: 1-844-202-6824
Attn: Prior Authorizations
PO Box 419069
Rancho Cordova, CA 95741
Standard and Fast Decisions
If you or your doctor believe that waiting 72 hours for a standard decision could seriously harm your health, you can ask for a fast (expedited) decision. This is only for Part D drugs that you have not already received. We must make expedited decisions within 24 hours after we get your doctor’s information.
If we approve your drug’s exception, the approval will be until the end of the plan year. To keep the exception in place, you must be enrolled in our plan, your doctor must continue to prescribe your drug, and your drug must be safe to treat your condition.
After we make a decision, we send you a letter telling you our decision. The letter has information on how to appeal.
If we deny your request for coverage of (or payment for) a drug, you, your doctor, or your representative can ask us for an appeal (redetermination). You have 60 days from the date of our denial letter to ask for a redetermination. You can complete the Request for Redetermination form, but you do not have to use it.
- Request for Redetermination Form (PDF) - English (PDF)
- Request for Redetermination Form (PDF) - Spanish (PDF)
You can send the form or other written request by mail or fax to:
Contact Member Services
Attn: Appeals and Grievances/Medicare Operations
7700 Forsyth Blvd
Saint Louis, MO 63105
- Medicare Hospice Form (PDF)
- Link to the Centers for Medicare and Medicaid Services (CMS) Request for Medicare Prescription Drug Determination Form (for use by members)
Information last updated: 05/20/2019