CareMore Cal MediConnect

Coverage Decisions & Prior Authorizations

What to do if you have problems getting a drug through your pharmacy benefit or you want us to pay you back for a drug:

You can ask for a Coverage Determination, also known as a Coverage Decision. Here are some examples of coverage decisions you can ask us to make about your pharmacy benefits:

  • You can ask us to make an exception.
  • You can ask us for a drug that is on the plan's Drug List, but has certain limits and requires approval before we will cover it for you. You can use this document to learn more about these limits
  • You can ask us to pay for a prescription drug you already bought. This is asking for a coverage decision about payment.

What is an exception?

An exception is a type of coverage decision. An exception is permission to get coverage for a drug that is not normally on our List of Covered Drugs, or to use the drug without certain rules and limitations. If a drug is not on our List of Covered Drugs, or is not covered in a way you would like, you can ask us to make an "exception."

When you ask for an exception, your doctor or other prescriber will need to explain the medical reason why you need the exception. Here are examples of exceptions:

  • Asking us to cover a Part D drug that is not on the plan's List of Covered Drugs (Drug List)
  • 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)

Important things to know about asking for exceptions

Your doctor or other prescriber must give us a statement explaining the medical reasons for requesting an exception. Our decision about the exception will be faster if you include this information from your doctor or other prescriber when you ask for the exception.

Typically, our Drug List includes more than one drug for treating a particular condition. These different possibilities are called "alternative" drugs. If an alternative drug would be just as effective as the drug you are asking for, and would not cause more side effects or other health problems, we will generally not approve your request for an exception.

How to ask for a coverage decision:

  • Ask for the type of coverage decision you want. Call, write or fax us to make your request. You can also fill out an on-line request. You, your representative or your doctor (or other prescriber) can do this.
  • If you are requesting an exception, provide the "supporting statement." Your doctor or other prescriber must give us the medical reasons for the drug exception. We call this the "supporting statement."

How to ask for a coverage decision for your pharmacy benefit:

Our plan has 72 hours (for a standard request) or 24 hours (for a fast request) from the date we get the required information to let you know our decision. We will give you an answer on reimbursing you for a Part D drug you already paid for within 14 calendar days.

We will say Yes or No to your request for an exception

If we say Yes to your request for an exception, the exception usually lasts until the end of the calendar year for most drugs. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.

If we say No to your request for an exception, you can ask for a review of our decision by making an appeal.

Who can make a coverage decision request?

Your doctor or other provider can ask for a coverage decision on your behalf.  Your doctor or prescriber does not need to complete the Appointment of Representative form for coverage decision requests.

You can name another person to act for you as your “representative” to ask for a coverage decision.

If you want a friend, relative, or other person to be your representative, call Member Services and ask for the “Appointment of Representative” form.  You can also get the form on the Medicare website by clicking the link below.  You must complete and submit the form to give the person permission to act for you. You can also send a written statement instead of the form. It must be signed and dated by both you and your representative. The statement must include:

  • Your name, address and phone number
  • Your Medicare Health Insurance Claim Number (HICN) number
  • The name, address and phone number of your representative
  • A statement that you are giving permission for the representative to act on your behalf
  • Your signature and date
  • The signature of the person who will represent you, their agreement to represent you and the date they agreed to represent you.

CMS Link to Appointment of Representation form HERE.