A coverage determination is the initial decision made by, or on behalf of, a Part D plan sponsor regarding payment or benefits to which an enrollee believes he/she is entitled to. A coverage determination is any decision made by the plan related to:
The coverage determination may be requested by your doctor, you as a Member or an authorized representative that has completed the plan’s required Appointment of Representative document. The request may be made orally or in writing. To protect your privacy and to confirm your identity, a representative of our plan could contact you, you doctor or authorized representative, to ask you for additional information or documentation.
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If the request does not involve an exception, we will notify the member the decision within 24 hours (expedited request) or 72 hours (standard application). If it is an exception request, this period begins when the doctor submits to plan medical justification. If the request is not approved, the decision shall be notified along with the information needed to apply for a plan redetermination.
For more information, contact Member Services or refer to Chapter 9 of your plan’s Evidence of Coverage.
The first step in requesting an exception is to contact the plan. Your plan will explain how to submit the information they need to make a decision. The plan may request the information in writing. They also can choose to accept the information over the phone. Your physician must submit a written statement supporting your request. The doctor's statement must establish that the requested drug is "medically necessary" for treating your condition. Once your doctor’s statement is received, your plan must notify you of its decision within 24 to 72 hours.
An exception is a type of coverage determination. You can ask us to make an exception to our coverage rules in a number of situations:
Generally, we will only approve your request for an exception if the alternative drugs included in the plan Formulary or the drugs in the non-preferred/highest tier subject to the tier exception process would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
Your physician must submit a statement supporting your exception request. In order to help us make a decision more quickly, you should include supporting medical information from your doctor when you submit your exception request. The plan will issue a decision on the case in a period of 72 hours (standard request) after receiving the written statement from your doctor. If you believe that the 72 hours review period may adversely affect your health, you may request an expedited decision. Simply state in the request that an expedited review is necessary and a decision will be issued within a period of 24 hours or less from the receipt of the doctor’s statement.
If we approve your exception request, our approval is valid for the rest of the plan year, as long as your doctor continues to prescribe the drug for you and it continues to be safe and effective for treating your condition. If we deny your exception request, you can appeal our decision.
Note: If we approve your exception request for a non-formulary drug, you cannot request an exception to the copay or coinsurance amount we require you to pay for the drug.
To learn more about how to request a standard exception or expedited exception, see chapter 9, under section “What is an exception?” of your plan’s Evidence of Coverage or call Member Services.
Plans are expected to disclose exception data, upon request, to individuals eligible to elect a Medicare Advantage organization or a Part D Sponsor. If you are interested in receiving this information, please contact Member Services.
Medicare y Mucho Más (MMM) (HMO), PMC Medicare Choice (PMC) (HMO) and FIRST+PLUS (PPO), products offered by MMM Healthcare, LLC, are plans with a Medicare contract. Enrollment in the plans depends on contract renewal. To enroll, you must have Medicare Parts A and B, have not been diagnosed with End Stage Renal Disease (ESRD) and reside within the 78 municipalities of the Island. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premium and/or co-payments/co-insurance 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. Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next. MMM Healthcare, LLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-333-5470. (TTY: 1-866-333-5469). Lunes a domingo, de 8:00 a.m. a 8:00 p.m.
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