Coverage Decision for Drugs

Step-by-step: How to ask for a coverage decision (prior authorization), including an exception, for Part D drug

Step 1: You ask us to make a coverage decision about the drug(s) or payment you need. If your health requires a quick response, you must ask us to make a “fast coverage decision.” You cannot ask for a fast coverage decision if you are asking us to pay you back for a drug you already bought.

What to do
  • Request the type of coverage decision you want. Start by calling, writing, or faxing us to make your request. You, your representative, or your doctor (or other prescriber) can do this. You can also access the coverage decision process through our website. For the details, go to Chapter 2, Section 1 and look for the section called, How to contact us when you are asking for a coverage decision about your Part D prescription drugs. Or if you are asking us to pay you back for a drug, go to the section called, Where to send a request that asks us to pay for our share of the cost for medical care or a drug you have received.

Method

Coverage Decisions for Medical Care – Contact Information

Call

1-888-254-9907 - Calls to this number are free. Hours are 8 a.m. to 8 p.m., seven days a week from October 1 through March 31, except holidays, and 8 a.m. to 8 p.m., Monday through Friday, from April 1 through September 30, except holidays. Messages received on holidays and outside of our business hours will be returned within one business day.

TTY 711

This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.

Fax

1-858-790-7100

Write

MedImpact HealthCare Services
Attn: Prior Authorization Department
10181 Scripps Gateway Court
San Diego, CA 92131

Click here to download the Drug Coverage Decision (Coverage Determination) Request Form: English | Spanish

Download Adobe Acrobat Reader

For expedited requests, please call or fax using the contact numbers above.

  • We must accept any written request, including a request submitted on the CMS Model Coverage Determination Request Form, which is available on our website.

You can request a coverage decision online. Click here to access the online request form.

If your health requires it, ask us to give you a “fast coverage decision”
  • When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard coverage decision means we will give you an answer within 72 hours after we receive your doctor’s statement. A fast coverage decision means we will answer within 24 hours after we receive your doctor’s statement.
  • To get a fast coverage decision, you must meet two requirements:
    • You can get a fast coverage decision only if you are asking for a drug you have not yet received. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.)
    • You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.
  • If your doctor or other prescriber tells us that your health requires a “fast coverage decision,” we will automatically agree to give you a fast coverage decision.
  • If you ask for a fast coverage decision on your own (without your doctor’s or other prescriber’s support), we will decide whether your health requires that we give you a fast coverage decision.
    • If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will send you a letter that says so (and we will use the standard deadlines instead).
    • This letter will tell you that if your doctor or other prescriber asks for the fast coverage decision, we will automatically give a fast coverage decision.
    • The letter will also tell how you can file a complaint about our decision to give you a standard coverage decision instead of the fast coverage decision you requested. It tells how to file a “fast complaint,” which means you would get our answer to your complaint within 24 hours of receiving the complaint.

Step 2: We consider your request and we give you our answer.

Deadlines for a “fast coverage decision”
  • If we are using the fast deadlines, we must give you our answer within 24 hours.
  • If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 24 hours after we receive your request or doctor’s statement supporting your request.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how to appeal.
Deadlines for a “standard coverage decision” about a drug you have not yet received
  • If we are using the standard deadlines, we must give you our answer within 72 hours.
  • If our answer is yes to part or all of what you requested –
    • If we approve your request for coverage, we must provide the coverage we have agreed to provide within 72 hours after we receive your request or doctor’s statement supporting your request.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how to appeal.
Deadlines for a “standard coverage decision” about payment for a drug you have already bought
  • We must give you our answer within 14 calendar days after we receive your request.
  • If our answer is yes to part or all of what you requested, we are also required to make payment to you within 14 calendar days after we receive your request.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how to appeal.

Step 3: If we say no to your coverage request, you decide if you want to make an appeal.

  • If we say no, you have the right to request an appeal. Requesting an appeal means asking us to reconsider – and possibly change – the decision we made.

For more information on the medical care coverage decision process, you may refer to Chapter 9 Section 6 of the Evidence of Coverage (EOC).

You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to file a grievance, request a coverage decision, or make an appeal at any level of the process. Go to “How to Appoint a Representative” page to find out more.

You may ask to obtain the aggregate numbers of the plan’s grievances, appeals, and exceptions. Please contact Vitality Member Services Department at 1-866-333-3530 (TTY: 711). Hours are 8 a.m. to 8 p.m., seven days a week from October 1 through March 31, except holidays, and 8 a.m. to 8 p.m., Monday through Friday, from April 1 through September 30, except holidays. Messages received on holidays and outside of our business hours will be returned within one business day.

Last updated 02/22/2019