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Coverage Decisions

A coverage decision (also called coverage determination) is a decision we make about your benefits and coverage or the amount we will pay for your drugs. You can ask us for a coverage decision if:

  • You need a drug that isn’t on our formulary, or need us to waive a rule or restriction we have on a drug we cover. Learn more about exceptions.
  • You want us to cover a drug on our formulary and you believe you meet any rules or restrictions we have for this drug.
  • You want us to pay you back for a drug you already got and paid for.

How do I request an exception or other coverage decision?

You, your prescriber, or your representative can request a coverage decision. For exception requests, we also need a statement from your prescriber supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) decision if you or your prescriber believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your prescriber.

If you are asking for a coverage decision without a prescriber’s support, we generally must make our decision within 72 hours of getting your request. If you request an expedited decision and it’s granted, we must give you a decision no later than 24 hours after we get your request.

To request an initial coverage decision by phone, call us at 1-866-901-8000 (TTY 711).

To request a coverage decision in writing, please include your name, date of birth, member ID number, the drug name (and strength and directions), the amount of drug you need and your doctor's name and phone number. You can use the CMS Request form linked below. If you’re requesting reimbursement, also include the amount you paid. You can use the Member Reimbursement form below. (Use of the forms is optional.)

You can drop off your request in person, fax it to 1-866-371-3239 or mail it to:

Attention: Pharmacy Dept.
Health Partners Medicare 
901 Market Street, Suite 500 
Philadelphia, PA 19107

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