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Appeals and Exceptions: Requesting Coverage Step by Step
Step 1: Request a formulary exception.
You can usually find the formulary on your plan's Web site or by calling
the member services phone number on the back of your pharmacy benefit
ID card.
You can also use the Formulary Finder at www.medicare.gov or call
1-800-MEDICARE (1-800-633-4227) to find plans in your state that cover
the medications you need.
A formulary exception is a type of coverage determination. In this step your plan makes a formal decision about whether or not to cover your medication.
How to Request: You, your appointed representative, or your health
care provider may make this request by phone or in writing to your
plan. No matter who does this, your plan must receive a statement
from your health care provider explaining the medical reason you need
the specific drug.
Timeframe: You may make this request at any time.
Decision: A decision must be made and sent to you as soon as your
clinical condition requires, but no later than 72 hours (24 hours for an
expedited request) after your health care provider's statement is
received.
| Step 1
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Request a formulary exception |
| Step 2
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Request a redetermination. |
| Step 3
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Request a reconsideration. |
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