When to Request a Drug Coverage Determination

Certain drugs require a determination before they can be covered. If your medication requires this step, you, your appointed representative or the doctor who prescribed it will need to request and receive approval for CarePlus to cover it. If a request was denied, you may submit a request for redetermination (submit an appeal).

Why is Drug Coverage Determination Required?

Determination is required for certain high-risk or high-cost medications. We want to make sure these medications do not interfere with others you take or add to your costs unnecessarily.

How to Request Drug Coverage Determination

There are several ways you, your representative or your prescribing doctor can submit your request.

Ask your Doctor to Submit a Request for You

Your prescribing doctor can call the following number or submit a request online.

Call the CarePlus Pharmacy Utilization Management Unit

1-866-315-7587

We are available Monday - Friday, 8 a.m. to 8 p.m.

If your prescribing doctor calls this number, we can answer any questions and provide a coverage determination form specifically for the requested drug. Then your doctor can submit the completed form by fax at: 1-800-310-907

Submit the Request Online

Complete the Coverage Determination Request Form in English or Spanish

This is a general form that is not specific to your drug. The CarePlus Pharmacy Utilization Management Unit may need to contact your prescriber for additional information before we can make a determination for the drug.

If You or Your Representative Submits Your Request

You or your representative may call or submit your request online, by fax, or by mail.

Call CarePlus Member Services with your Request

1-800-794-5907 (TTY: 711)

Submit your request online

Complete the Coverage Determination Request Form in (English or Spanish)

You will need to submit supporting documents from your prescribing doctor to help us determine if you medically need the requested medication. Your information will be sent to us securely.

Fax or mail the form

Download a copy of the form below and fax or mail it to CarePlus:

Prescription Drug Coverage Determination Request Form - English

Prescription Drug Coverage Determination Request Form - Spanish

You can also access Medicare’s Part D Coverage Determination Request Form on the CMS website.

Fax your form:
1-800-310-9071

Mail your form:
CarePlus Health Plans
Attention: CarePlus Pharmacy Utilization Management Unit
P.O. Box 277810
Miramar, FL 33027

If a representative (other than you or your doctor) submits the request for you, please provide a legal representation form with your request or make sure you have completed an Appointment of Representative Form. Otherwise we will not be able to process your request.

We will let you know if the request was approved or denied no later than 72 hours for standard requests or 24 hours for expedited requests, once it has been received. For exceptions, the timeframe begins when we obtain your prescriber’s supporting statement. Your request will be expedited if we determine or if your prescriber tells us that your life, health, or ability to regain maximum function may be seriously jeopardized by waiting for a standard decision.
 

What if we determine your prescription drug is not covered?

In some cases CarePlus might deny your request for coverage of a prescription drug. If we deny all or part of your request, we will send you a detailed written explanation and instructions on how to appeal our decision if you disagree.

If you appeal (and ask us to reconsider our decision), please be sure to submit all supporting information along with your appeal request.

Once we receive the request, we will make a decision and provide written notice of our decision within 14 calendar days for payment requests, 7 calendar days for standard drug coverage requests, or 72 hours for expedited requests (for drug benefits). If you have questions about our process or the status of your request, please call Member Services.

How to obtain grievance, coverage determinations (including Medicare Part D exceptions) and appeal data.

You can find detailed information in Chapter 9 of the CarePlus Evidence of Coverage (EOC) with regard to grievances, coverage determinations (including exceptions), and the appeals process. You will find links to the EOC on the CarePlus Medicare Advantage Plan Information pages.

To obtain information on the aggregate number of grievances, coverage determinations (including Medicare Part D exceptions), and appeals filed with the plan, please call Member Services at 1-800-794-5907 (TTY: 711). From October 1- March 31, we are open 7 days a week, 8 a.m. to 8 p.m. From April 1- September 30, we are open Monday-Friday, 8 a.m. to 8 p.m. You may always leave a voicemail message after hours, Saturdays, Sundays, and holidays and we will return your call within one business day.