Prescription Drug Coverage

This section describes your rights to request coverage of a Part D prescription drug or payment for a Part D prescription drug that you have purchased. You also may make a complaint about your prescription drug benefits and coverage.

Introduction

To learn about your prescription drug benefits and coverage, please review Medicare – Approved Prescription Drug Coverage in Chapter 9 of your Evidence of Coverage. To review, select your plan below:

Coverage Determinations

You have the right to ask for a Part D prescription drug benefit. The first step is called requesting a "coverage determination."  A form is available for you to use, although using the form is not required (Request for Medicare Prescription Drug Coverage Determination Form). When we make a coverage determination, we are making a decision whether to provide or pay for a Part D drug and what your share of the cost is for the drug. (Coverage determinations include exceptions requests.) The following are examples of coverage determinations:

  • You ask us to pay for a prescription drug that you have received. This is a request for coverage determination about payment.
  • You ask for a Part D drug that is not on CHP's list of covered drugs (called a "formulary"). This is a request for a "formulary exception."
  • You ask for an exception to our utilization management tools, such as prior authorization, dosage limits, quantity limits, or step therapy requirements. These are types of "formulary exceptions."
  • You ask for a non-preferred Part D drug at the preferred cost-sharing level. This is a request for a "tiering exception."
  • You ask us to pay you back for a drug that you bought at an out-of-network pharmacy.

There are Three Kinds of Coverage Determinations That You Can Request

Fast (Expedited) (24 hours) - You can request a fast coverage determination:

  • If your doctor or other prescriber asks for a fast determination for you, or supports you in asking for one, and the doctor or other prescriber indicates that waiting for a standard determination could seriously harm your health or your ability to function, we automatically will give you a fast determination.
  • If you ask for a fast coverage determination without support from a doctor or other prescriber; we will decide if your health requires a fast determination.

Standard coverage decision about a drug you have not yet received (72 hours) - Any request for a Part D drug that you have not yet purchased and that does not need to be decided within 24 hours for protection of your health or ability to function will be decided as a standard determination.

Standard coverage decision about payment for a drug you have already purchased (14 calendar days) - Any request for payment for a Part D drug you have already purchased will be decided as a standard determination.

Exception

An exception is a type of coverage determination. Whenever you request an exception, your doctor or other prescriber must submit a statement and supporting information about the medical need for the exception. A request for an exception will be approved only when there is a medical reason for it. If you request an exception, your doctor or other prescriber must provide a statement to support your request. You have the right to ask us for an "exception" if you want us to:

  • waive coverage restrictions on your drug
  • provide a higher level of coverage (and, thus, a lower copayment) for your drug

You can ask us to make the following exceptions to our coverage rules for Part D prescription drugs:

  • Formulary Exception 

    You can make a request for an exception for drugs that have coverage restrictions, including quantity limits, step therapy requirements, and prior authorization. You may ask for coverage of a Part D drug that is not on Capital Health Plan's formulary.

    If the exception is approved, arrangements will be made to cover the drug for the remainder of the plan year, up to your pharmacy benefit limit, and you will be notified of the approval. If the exception is denied, you will be notified of the decision and given information about your appeal rights.

  • Tiering Exception 

    You can ask us to provide a higher level of coverage for your drug.

    If the exception is approved, arrangements will be made to cover the requested drug at the Tier 2 copayment for the remainder of the plan year, up to your pharmacy benefit limit, and you will be notified of the approval. If the exception is denied, you will be notified of the decision and given information about your appeal rights.

Capital Health Plan will notify you and your doctor or other prescriber of our decision about a standard request for an exception as quickly as your health condition requires, but no later than 72 hours after we receive the required information from your doctor or other prescriber. Our notification will be given within 24 hours after we receive the required information from your doctor or other prescriber if he or she indicates that waiting for a standard determination could seriously harm your health or your ability to function. If your doctor or other prescriber does not provide us with the required information, we will wait up to 45 days before we make our decision. If your doctor or other prescriber does not provide the requested information within 45 days, we will make our decision with the information that we have.

If we receive the supporting statement from your doctor or other prescriber and we do not provide a timely response, your request automatically is sent for review to an Independent Review Organization.

Please see Part D Exceptions below for details of the exceptions process.

How Do I Request a Coverage Determination?

A form is available for you to use, although using the form is not required

Request for Medicare Prescription Drug Coverage Determination Form.

Asking for a standard decision: You, your doctor or other prescriber, or your appointed representative (Appointment of Representative Form) may contact us by telephone or fax at the numbers below:

Telephone:
(850) 523-7411 or 1 (877) 247-6512; 8:00 a.m. – 8:00 p.m., seven days a week, October 1 – March 31; 8:00 a.m. – 8:00 p.m., Monday – Friday, April 1 – September 30. State of Florida members call 1-877-392-1532, 7:00 a.m. – 8:00 p.m.

Fax:
800-693-6703

Email:  You may request a coverage determination by sending a message directly to Member Services.

Deliver:
Capital Health Plan 
1545 Raymond Diehl Road, Suite 300 
Tallahassee, FL 32308

Asking for a fast decision: You, your doctor or other prescriber, or your appointed representative (Appointment of Representative Form) may contact us by telephone or fax at the numbers above. Be sure to ask for a "fast," "expedited," or "24-hour" review.

Complaints

You may make a complaint if you have concerns or problems about your prescription drug benefits or coverage. A complaint will be handled as an "appeal" or a "grievance," depending on the subject of the complaint.

An "appeal" is a review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision that we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug. You cannot request an appeal if we have not issued a coverage determination.

A "grievance" is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with Capital Health Plan's Medicare program or one of our network pharmacies that does not relate to coverage for a prescription drug. For example, you would file a grievance if you have a problem such as waiting times when you fill a prescription, the way your network pharmacist or others behave, being able to reach someone by telephone or get the information that you need, or the cleanliness or condition of a network pharmacy.

Grievances

There are Two Kinds of Grievances That You Can Request:

Fast (Expedited) (24 hours) - This is for if you disagree with our decision not to give you a fast decision on prescription drug coverage. We must respond to this type of grievance within 24 hours of the time we receive it.

Standard (30 days) - Any other type of complaint. We must respond to this type of grievance as promptly as your medical condition requires, but no later than 30 calendar days from the date we receive it.

How Do I Submit a Grievance?

You or your appointed representative (Appointment of Representative Form) may call Member Services or you may write to us. If you submit a written grievance, you will get an answer in writing. If you submit a verbal grievance, you will get an answer by telephone, unless you ask for an answer in writing. All quality of care grievances will be answered in writing.

For an Expedited Grievance: You or your appointed representative (Appointment of Representative Form) should contact us by telephone or fax at the numbers below:

Telephone: 
(850) 523-7411 or 1 (877) 247-6512; 8:00 a.m. – 8:00 p.m., seven days a week, October 1 – March 31; 8:00 a.m. – 8:00 p.m., Monday – Friday, April 1 – September 30. State of Florida members call 1-877-392-1532, 7:00 a.m. – 8:00 p.m.

Fax:
850-383-3413

For a Standard Grievance: You or your appointed representative (Appointment of Representative Form) should call, mail, or deliver your grievance request to the address/number below:

Mail:
Capital Health Plan 
Attention: Member Services 
P.O. Box 15349 
Tallahassee, FL 32317-5349

Deliver: 
Capital Health Plan, Member Services Department
1545 Raymond Diehl Road, Suite 300
Tallahassee, FL 32308

Telephone:
850-523-7441 (1-877-247-6512 toll-free) (TTY 850-383-3534 or 1-877-870-8943 toll-free) 8:00 a.m. - 8:00 p.m., seven days a week, October 1 - February 14; 8:00 a.m. - 8:00 p.m., Monday - Friday, February 15 - September 30.  

Quality of Care Complaints:

If you are concerned about the quality of care that you received, you also can complain, in writing, to an independent organization:

KEPRO  
5201 W. Kennedy Blvd., Suite 900 
Tampa, FL 33609

Phone: 1-888-317-0751, Fax: 1-833-868-4058, TTY: 1-855-843-4776

Appeals

If we deny your request, we will send you a written decision explaining the reason(s). Please consult Chapter 9 of your Evidence of Coverage for more detailed information on prescription drug benefits/coverage appeals.

If we deny part or all of your request in our coverage determination, you may ask us to reconsider our decision. This is called an "appeal" or "request for redetermination."  A form is available for you to use, although using the form is not required (Request for Redetermination of Medicare Prescription Drug Denial).  Please call us at 850-523-7441 or 1-877-247-6512 (TTY 850-383-3534 or 1-877-870-8943) 8:00 a.m. – 8:00 p.m., seven days a week, October 1 – March 31; 8:00 a.m. – 8:00 p.m., Monday – Friday, April 1 – September 30.  State of Florida members call 1-877-392-1532, 7:00 a.m. – 8:00 p.m. if you need help with filing your appeal. You may also request an appeal by emailing Member Services. You must appeal our denial within 60 calendar days of the date on the notice of our coverage determination. (We can give you more time if you have a good reason for missing the deadline.)

You may ask us to reconsider our coverage determination even if only part of our decision is not what you requested. If your appeal concerns a decision that we made about authorizing a Part D benefit that you have not received yet, you and/or your doctor or other prescriber first will need to decide whether you need a fast appeal. The rules about who may file an appeal are almost the same as the rules about who may ask for a coverage determination. For a standard request, you, your doctor or other prescriber, or your appointed representative (Appointment of Representative Form) may file the request. The rules about asking for a fast appeal are the same as the rules about asking for a fast coverage determination.

There are Two Kinds of Appeals That You Can Request

Fast (Expedited) (72 hours) - You can request an expedited (fast) appeal for cases that involve coverage if you or your doctor or other prescriber believe that your health could seriously be harmed by waiting up to 7 days for a decision. If your request to expedite is granted, you will receive a decision no later than 72 hours after your appeal is received.

  • If the doctor or other prescriber who prescribed the drug(s) asks for an expedited appeal for you, or supports you in asking for one, and he or she indicates that waiting for 7 days could seriously harm your health, the appeal automatically will be expedited.
  • If you ask for an expedited appeal without support from a doctor or other prescriber, we will decide whether your health requires an expedited appeal. If you do not get an expedited appeal, your appeal will be decided within 7 days.
  • Your appeal will not be expedited if you already have received the drug that you are appealing.

Standard (7 days) - You can request a standard appeal for a case that involves coverage or payment. You will receive a decision no later than 7 days after your appeal is received.

What Do I Include with My Appeal?

You should include your name, address, Member ID number, the reasons for appealing, and any evidence that you wish to attach. If your appeal relates to a decision by us to deny a drug that is not on our list of covered drugs (formulary), your doctor or other prescriber must indicate that all of the drugs on any tier of our formulary would not be as effective to treat your condition as the requested off-formulary drug or would harm your health.

What Happens Next?

If you appeal, we will review our decision. If we continue to deny the Part D drug or exception request, you may ask for a review by a government-contracted independent review organization. The denial letter will tell you how to start this outside appeal. If you disagree with the decision of the outside reviewer, you will have further appeal rights. You will be notified of those appeal rights if this happens.

Contact Information

If you need information or help, or would like to obtain an aggregate number of grievances and appeals filed with this plan, call us at:

850-523-7441 or 1-877-247-6512 (TTY 850-383-3534 or 1-877-870-8943) 8:00 a.m. – 8:00 p.m., seven days a week, October 1 – March 31; 8:00 a.m. – 8:00 p.m., Monday – Friday, April 1 – September 30.  State of Florida members call 1-877-392-1532, 7:00 a.m. – 8:00 p.m. 

Other Resources To Help You

Medicare Rights Center: 1-888-HMO-9050 (toll-free)

Elder Care Locator: 1-800-677-1116 (toll-free)

1-800-Medicare (1-800-633-4227)

Part D Exceptions

This section gives information on what to do if you need to ask us to make an exception to our Part D prescription drug coverage rules.

**You cannot request coverage for a prescription drug that does not meet the definition of a Part D drug. There are a few specific drugs that your Medicare plan cannot cover.**

You can ask us to make the following exceptions to our coverage rules:

You can ask us to remove a coverage restriction or limit on your drug. This is called a Formulary Exception. For example, CHP limits the amount of certain drugs that we will cover; this is called a "quantity limit." If your drug has a quantity limit, you can ask us to remove the limit and cover more. In some cases, CHP requires that you first try one drug to treat a medical condition before we will cover another drug for that condition. This is called "step therapy." You can ask us to remove a step therapy requirement.

You can ask us to cover a Part D drug that is not on the CHP Formulary. This is called a Formulary Exception. Generally, a non-formulary drug is covered only if the alternative drug listed on the formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects. Drugs that Medicare does not cover are also excluded from coverage by CHP.

You can ask us to provide a higher level of coverage for your drug. This is called a Tiering Exception. For example, if your drug is a Tier 4 drug, you can ask us to cover it as a Tier 3 drug instead. This would lower the copayment/coinsurance amount that you would pay for the drug. (There are limitations to this type of request. You cannot request a change to the coinsurance on a Tier 5 drug. You cannot request a change from a Tier 3 copayment to a generic copayment, nor a change from a Tier 4 copayment to a generic copayment.)

Your doctor or other prescriber must submit a statement and supporting information about the medical need for the exception. 

A request for an exception will be approved only when there is a medical reason for it.

You may also request an exception by emailing Member Services.

You, your appointed representative, or your doctor or other prescriber may request an exception by calling us at one of the telephone numbers listed on this page or writing us at the address listed on this page. (A form is available for you to use, although using the form is not required: Request For Medicare Prescription Drug Determination Form.)

Capital Health Plan will notify you and your doctor or other prescriber of our decision about a standard request for an exception as quickly as your health condition requires, but no later than 72 hours after we receive the required information from your doctor or other prescriber. Our notification will be given within 24 hours after we receive the required information from your doctor or other prescriber if he or she indicates that waiting for a standard determination could seriously harm your health or your ability to function. If your doctor or other prescriber does not provide us with the required information, we will wait up to 45 days before we make our decision. If your doctor or other prescriber does not provide the requested information within 45 days, we will make our decision with the information that we have.

If we receive the supporting statement from your doctor or other prescriber and we do not provide a timely response, your request automatically is sent to the Independent Review Organization for review.

Request for a Formulary Exception

You can make requests for an exception for drugs that have coverage restrictions, including quantity limits, step therapy requirements, and prior authorization. You can request coverage for a Part D drug that is not on Capital Health Plan's formulary.

Your doctor or other prescriber must give Capital Health Plan information that the requested drug is more effective in treating your disease or condition or the restricted quantity is likely to be ineffective or adversely affect your compliance. The request from the doctor or other prescriber must be supported by sound clinical evidence and scientific literature. A Medical Director will review the request and the information provided by your doctor or other prescriber. The fact that your doctor or other prescriber submits a statement supporting your request does not mean that you will automatically receive approval of your request.

If the exception is approved, arrangements will be made to cover the requested drug or quantities of the drug, up to your pharmacy benefit limit, and you will be notified of the approval. You will not have to request a new approval before the end of the plan year as long as your doctor or other prescriber continues to prescribe the drug for your condition, the drug continues to be safe for treating your condition, and you remain enrolled in our plan. If you renew your membership in the CHP Medicare program, CHP may continue to cover the drug into the new plan year.

If the exception is denied, you will be notified of the decision and given information about your appeal rights.

Request for a Tiering Exception

Your doctor or other prescriber must give Capital Health Plan information that the drug you want at a lower copayment is more effective than the original drug or that the original drug has negative effects, or both. A Medical Director will review the request and the information provided by your doctor or other prescriber. The fact that your doctor or other subscriber submits a statement supporting your request does not mean that you will automatically receive approval of your request.

If the exception is approved, arrangements will be made to cover the requested drug at the approved copayment, up to your pharmacy benefit limit, and you will be notified of the approval. You will not have to request a new approval before the end of the plan year as long as your doctor or other prescriber continues to prescribe the requested drug for your condition, the requested drug continues to be safe for treating your condition, and you remain enrolled in our plan. If you renew your membership in the CHP Medicare program, CHP may continue to cover the drug into the new plan year.

If the exception is denied, you will be notified of the decision and given information about your appeal rights. Please review your Evidence of Coverage for more information about the Part D exceptions process.