What is a Coverage Determination?
A Coverage Determination is the initial decision we made about your coverage or payment for your care. With this decision, we inform you whether we will provide the care or services you request (a pre-service decision), or pay for a service you have already received. If our initial decision is to deny your request (which is also called an adverse coverage determination), you can file an Appeal.

There are different rules for coverage determinations depending on whether you are requesting coverage for medical services or coverage for prescription drugs.

Coverage Determinations about prescription drug benefits
If you or your doctor requests coverage for a Part D prescription drug, we must make a decision within 72 hours (for a standard request). If you or your doctor thinks that waiting for a standard decision could seriously harm your health or your ability to function, you can request an expedited or “fast” decision. We must respond to your request for a fast decision with 24 hours.

You are asking for an initial decision about prescription drug benefits if you:

• Ask for a Part D drug that is not on our formulary list. This is a request for a “formulary exception.”
• Ask for an exception for our plan’s utilization management techniques, such as step-therapy requirements or quantity limits. This is also considered to be a request for a formulary exception.
• Ask for a non-preferred Part D drug at the preferred cost level. This is a request for a “tiering exception.”
• Ask us to pay for a prescription drug you have already received. This is a request for an initial decision about payment.

Pre-Service Requests for Prescription Drug Benefits
Use the Medication Request Form (MRF) (requires Adobe Reader) to request prior authorization for a formulary drug, a formulary exception (coverage for a non-formulary drug) or a tiering exception.

The prescribing physician must sign the completed form and send it, with appropriate documentation of medical necessity, to:

Health Alliance Plan
C/O Medimpact Healthcare Systems, Inc
Attn: Prior Authorization Department
10680 Treena Street, Suite 500
San Diego, CA 92131
FAX: 1-858-578-9732

When you request an exception to the plan’s formulary or tiering structure, your physician must provide a “physician supporting statement.”

Physician Supporting Statement for a Formulary Exception
In order for us to consider a request for a formulary exception, the prescribing physician must provide an oral or written supporting statement that the requested drug is medically necessary to treat your condition because:

• All of the covered drugs on any tier of the formulary available for treatment of your condition would either not be as effective for you as the non-formulary drug and/or would be harmful for you; or
• The prescription drug alternatives listed on the formulary or required to be used in accordance with step therapy requirements has been ineffective in treating your condition or is likely to be ineffective, or has caused or is likely to cause harm to you; or
• The number of doses available under a dose restriction has been or is likely to be ineffective in treating your condition.

To request an exception or prior authorization, use the Medicare Part D Coverage Determination form (requires Adobe Reader).

Physician Supporting Statement for a Tiering Exception
In order for us to consider your request for a tiering exception, the prescribing physician must provide an oral or written supporting statement that the preferred (lower cost-sharing) drug(s) available for treatment of your condition would not be as effective for you as the requested drug, and/or would have adverse effects for you.

Post-Service (Payment) Requests for Prescription Coverage Benefits
Use the Direct Member Reimbursement Form (requires Adobe Reader): Alliance Medicare PPO Form | HAP Senior Plus Form | Alliance Medicare Rx Form [Coming soon] -- to a request reimbursement when you pay out of pocket for covered drugs.

Send the completed form (with detailed pharmacy receipt) to:

HAP Senior Plus/Alliance Medicare PPO
Attn: Pharmacy Care Management
2850 W. Grand Boulevard
Detroit, MI 48202

For more information, or to find out the status of your reimbursement request, call our Client Services Department.

Coverage Determinations about medical services
If you or your doctor requests coverage for medical services, we must make a decision within 14 calendar days (for a standard request). If you or your doctor thinks that waiting for a standard decision could seriously harm your health or your ability to function, you can request an expedited or “fast” decision. We must respond to your request for a fast decision with 72 hours.