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.

Coverage decisions 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.

For information on how to request an organization determination, click on the button below.

• How to request an Organization Determination (PDF) How to request an Organization Determination (PDF)

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 Request for Medicare Prescription Drug Coverage Determination form (PDF) to request prior authorization for a drug list drug, a formulary exception or a tiering exception.

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

Fax: (313) 664-8045

Have questions?

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