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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)


Fax: 1-877-941-0480

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).

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