For Members of Medicare and Medicaid

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Prescription Drug Documents

Coverage Determinations

To ask for a Coverage Determination or Exception about Medicare Part D prescription drugs, you may need to complete the  Description: PDF documentMedicare Prescription Drug Coverage Determination Form (106 MB). You may also ask us for a coverage determination by phone at 1-800-963-0035 or at this web link.

 

Online Coverage Determination Requests With PromptPA

The PromptPA website lets you and your health care providers submit Coverage Determination/ Prior Authorization requests online for your prescription drugs. You can also see the status and outcome of these requests on the site.

  • To get started, visit PromptPA and click on the "Members" link. You do not need to register.

 

Redetermination

To ask for a redetermination (appeal) of our decision when we deny your request for coverage of (or payment for) a prescription drug, you may complete the Description: PDF documentRequest for Redetermination of Medicare Prescription Drug Denial (45 KB)

More information about Grievance and Appeals and asking for a Coverage Determination or Exception about your medical care, and Medicare Part D prescription drugs is available on the Grievance and Appeal Process page. 

 

Description: PDF document Medication Management Therapy Programs (44 KB)

Description: PDF document Part D Formulary Transition Policy (95 KB)

Description: PDF document Medicare Part D Low-Income Subsidy Premium Assistance (81 KB)

Description: PDF document Multi-language Interpreter Services (163 KB)

 

If you need materials in other formats or languages, please contact us  or see Help in Other Languages.

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