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Coverage Determinations & Exceptions

Coverage Determination

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:


  • A prescription that a patient believes should be covered
  • A payment for a prescription that the patient believes should be covered
  • A request for an exception to the level of copay or to the Formulary
  • Member disagreement with the amount that the plan requires the member to pay for a Part D drug
  • Member disagreement with the quantity limit
  • Member disagreement with the requirements for step therapy (the member has to try another drug before the approval of the requested drug)
  • Member disagreement or dissatisfaction with a decision, preauthorization or requirement of utilization management
  • If your doctor or pharmacy informs you that a drug is not covered by the plan, you should contact your plan to request a coverage determination.


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.



    • Register online and streamline the process.
    • Call Member Services:

      Member Services

      787-620-2397 (Metro Area)
      1-866-333-5470 (Toll Free)
      1-866-333-5469 TTY (Hearing Impaired)


      Member Service

      787-625-2126 (Metro Area)
      1-866-516-7700 (Toll Free)
      1-866-516-7701 TTY (Hearing Impaired)


      Member Service

      787-522-7800 (Metro Area)
      1-888-767-7717 (Toll Free)
      1-877-672-4242 TTY (Hearing Impaired)


      Monday through Sunday, from 8:00 a.m. to 8:00 p.m.


    • Download and fill out the Request for Medicare Prescription Drug Coverage Determination and send it by email, fax or mail:

      Medicare y Mucho Más
      Pharmacy Department

      PO BOX 71114
      SAN JUAN PR 00936-8014
      Fax: 787-300-5503


      PMC Medicare Choice
      Pharmacy Department

      PO Box 366292
      San Juan PR 00936-6292
      Fax: 787-625-3370


      Pharmacy Department

      PO BOX 71114
      SAN JUAN PR 00936-8014
      Fax: 787-300-5503


    • If you send the request by email, be sure to include the following information:
      • Name and Last Name
      • Telephone number
      • ID Number
      • Attach the completed form

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:

  • You may request us to cover your drug even if it is not on our Formulary. Excluded drugs cannot be covered by a Part D plan unless coverage is through an enhanced plan.
  • You may request to have us waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
  • You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our non-preferred/highest tier subject to the tier exception process, you may request us to cover it at the cost-sharing amount that applies to drugs in the preferred/lowest tier subject to the tier exception process tier instead. This will lower the coinsurance/copay amount you must pay for your prescription. Please note, if we grant your request to cover a drug that is not on our Formulary, you may not ask us to provide a higher level of coverage for the drug. You may neither ask us to provide a higher level of coverage for drugs that are in the tier designated as the high cost/unique drug tier.

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.