A coverage determination is the first decision we make about whether we will cover a drug you are requesting that is not on our Formulary, requires an exception to our Formulary, or is considered a non-covered medication. A coverage determination may be requested by you, your physician or your appointed representative. If we deny a coverage determination, you may file a complaint or request for reconsideration.

View or download a Coverage Determination form.

An exception is a coverage determination that involves a request to cover a drug not on our Formulary, waiving restrictions or limits such as dose limits, or changing the cost sharing amount you pay. An exception must be requested by your physician.

The process for Prescription Drug Grievances and Appeals is similar to that for hospital and medical care. There are two different ways to file complaints under the drug program: a grievance, or an exception/appeal request, depending on the subject of the complaint.

• A grievance is any complaint that doesn't involve a coverage decision. Some examples are if you have to wait too long for a prescription to be filled at the pharmacy or your pharmacy is charging you more than you think they should.
• An appeal is made when you receive an unfavorable coverage determination. There are five levels in the appeals process. An Appeal Level 1 is the starting point and may only be submitted if we first deny a coverage determination. You must start the process within 60 days of receiving a denial or partial denial of a coverage determination.

For more information on Grievances and Appeals for Prescription Drug Services, please refer to Sections [10] of the Evidence of Coverage. View or download the Evidence of Coverage booklet.