Coverage Determinations and Exceptions

What is a coverage determination?

A coverage determination is a decision Superior STAR+PLUS MMP makes about whether a drug written for you is covered by the plan and the amount, if any, you will have to pay for the drug. Coverage determinations are also called coverage decisions.

What is an exception?

If a drug is not covered in the way you would like it to be covered you can ask us to make an “exception.” An exception is a type of coverage determination. Similar to other types of coverage determinations, if we turn down your request for an exception, you can appeal our decision. When you ask for an exception, your doctor or other prescriber will need to explain the medical reason(s) why you need the exception approved. We will then consider your request.

Asking for a coverage determination or exception

You, your physician or your appointed representative may file for a coverage determination including an exception. Please see contact information below.

Phone: 1-866-399-0928

TTY: 711

Fax: 1-877-941-0480

Please see below for the Medicare Prescription Drug Coverage Determination Request Form. You cannot use this form for Medicare non-covered drugs: fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over the counter drugs or prescription vitamins (except prenatal vitamins and fluoride preparations).

You may use the following forms to submit your appeal request:

Drug Coverage Determination Form

Determinación de Cobertura de Medicamentos Formulario

Request for Redetermination Form

For more information, call the Member Services department at 1-866-896-1844. Hours are 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. 

Last Updated: 09/30/2017
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