What is a coverage decision?
A coverage decision is an initial decision we make about your benefits and coverage or about the amount we will pay for your medical services, items, or drugs. We are making a coverage decision whenever we decide what is covered for you and how much we pay. If you or your doctor are not sure if a service, item, or drug is covered by Medicare or Medi-Cal, either of you can ask for a coverage decision before the doctor gives the service, item, or drug.
Where can a coverage decision be filed?
You, your representative or your doctor can request a coverage decision by:
- Mailing your request to:
- MMP Complaints, Appeals & Grievances
12900 Park Plaza Drive,
Cerritos, CA 90703
- Faxing your request to 1-888-426-5087
- Calling Member Services at 1-888-350-3447 (TTY: 711)
Monday - Friday 8 a.m. to 8 p.m. PST.
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 or make an appeal.
- 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. The form will give the person permission to act for you. You must give us a copy of the signed form with your request.
- CMS Link to Appointment of Representation form HERE.
How long does it take to get a coverage decision?
It usually takes up to 14 calendar days after you asked. If we don't give you our decision within 14 calendar days, you can appeal. Sometimes we need more time and we will send you a letter telling you that we need to take up to 14 more calendar days.
If you need a response faster because of your health, you should ask us to make a "fast coverage decision." If we approve the request, we will notify you of our decision within 72 hours. However, sometimes we need more time and we will send you a letter telling you that we need to take up to 14 more calendar days.
Here are the rules for asking for a fast coverage decision:
You must meet the following two requirements to get a fast coverage decision:
- You can get a fast coverage decision only if you are asking for coverage for a drug you have not yet received. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you already bought).
- You can get a fast coverage decision only if the standard 14-calendar-day deadline could cause serious harm to your health or hurt your ability to function
- If your doctor or prescriber says that your health requires a fast coverage decision, we will automatically agree to give you a fast coverage decision
- If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will use the standard deadline instead
Coverage Decisions for your Part D Drugs
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 ask us to make an exception
- You 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 the Prior Authorization Criteria 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.
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 are called "alternative" drugs. If an alternative drug would be just as effective as the drug you are asking for, and not cause 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, your representative, or your doctor (or other prescriber) can do this. You can call us at 1-800-350-3447 (TTY 711) 8 a.m. to 8 p.m. PST Monday through Friday.
- You do not need to give your doctor or other prescriber written permission to ask us for a coverage decision on your behalf.
- 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".
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.