Determinations

Learn how we make decisions about coverage and payments

A coverage determination is the initial decision we make about your coverage or payment for a prescription drug request. An organization determination is the initial decision we make about your coverage or payment for medical services.

With these decisions, we inform you whether we’ll provide the care or services you request (a pre-service decision), or pay for a service you’ve already received.

How we make determinations

We make determinations based only on the appropriateness of care and service and the existence of coverage. We don’t specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service. Furthermore, we don’t offer financial incentives to encourage inappropriate underutilization of covered services.

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

If our initial decision is to deny your request (also called an adverse coverage determination), you can file an appeal.

Organization 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 waiting for a standard decision could seriously harm your health or ability to function, you can request an expedited or “fast” decision. We must respond to your request for a fast decision within 72 hours.

Coverage determinations about prescription drug benefits

If you or your doctor requests coverage for a Medicare Part D prescription drug, we must make a decision within 72 hours for a standard request.

If you or your doctor thinks waiting for a standard decision could seriously harm your health or 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’re asking for an initial decision about prescription drug benefits if you:

  • Ask for a Part D drug not on our drug list, also called a formulary. 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 also is considered to be a request for a “formulary exception.”
  • Ask for a nonpreferred 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’ve already received. This is a request for an initial decision about payment.

Learn more about exceptions for prescription drugs.

Pre-service requests for prescription drug benefits

Use the Medicare Part D Coverage Determination Request Form (PDF) to request prior authorization for a drug list drug, a formulary exception or a tiering exception. You must have Adobe Reader to download PDF files. Download Adobe Reader for free.

Send the completed form, with appropriate documentation of medical necessity, to:

Health Alliance Plan
Attn: Pharmacy Care Management
2850 W. Grand Blvd.
Detroit, MI 48202

Fax: (313) 664-8045

Have questions?

Send us an email, or give us a call. Contact us.

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Copyright © 2017 HAP
2017 Health Alliance Plan of Michigan
Y0076_ALL_2018029 Website MP
CMS Approved: 6/26/2017
Last Update: 6/21/2017

HAP Senior Plus HMO, HMO-POS, and PPO are health plans with a Medicare contract. Enrollment in these plans depends on contract renewal. HAP Senior Plus PPO is a product of Alliance Health and Life Insurance Company, a wholly owned subsidiary of HAP. Alliance Medicare Supplement is a product of Alliance Health and Life Insurance Company, a wholly owned subsidiary of HAP.

This information is not a complete description of benefits. Contact the plan for more information. Limitation, copayments, and restrictions may apply. Benefits, premiums, and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The formulary, pharmacy network, and or provider network may change at any time. You will receive notice when necessary.

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Contact us

  • (800) 868-3153 TTY: 711

  • HAP Senior Plus®

    (800) 801-1770 TTY: 711

  • HAP Senior Plus® (PPO)

    (888) 658-2536 TTY: 711

  • Alliance Medicare Supplement:

    (800) 873-7526 TTY: 711