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Coverage Determinations and Redeterminations for Drugs

A coverage determination is a decision about whether a drug prescribed for you will be covered by us and the amount you’ll need to pay, if any. If a drug is not covered or there are restrictions or limits on a drug, you may request a coverage determination.

You can ask us to cover:

  • a drug that is not on our List of Drugs (Formulary).
  • a drug that requires prior approval.
  • a drug at a lower cost sharing tier.
  • a higher quantity or dose of a drug.

You, your representative, or your doctor may submit a coverage determination request by fax, mail or phone. You must include your doctor’s statement explaining why your drug is necessary for your condition. Within 72 hours after we receive your doctor’s statement, we must make our decision and respond. If we deny your request you can appeal our decision. Information on how to file an appeal will be included in the denial notice.

Generally, we will approve your request only if the alternative drug is on our list of drugs, or if a lower cost-sharing drug or added restrictions don’t treat your condition as well. The contact information is listed below. You also can contact Member Services.

You may use this form to submit your request:

You can submit the Coverage Determination form through our secure online portal.

Phone: 
Members: 1-866-896-1844
TTY:711

Doctors and Other Prescribers: 1-800-867-6564
TTY: 711

Fax:
1-877-941-0480

Mail:
Superior HealthPlan STAR+PLUS Medicare-Medicaid (Medicare-Medicaid Plan)
Medicare Part D Prior Authorization Department  
PO Box 419069 
Rancho Cordova, CA 95741

Standard and Fast Decisions

If you or your doctor believe that waiting 72 hours for a standard decision could seriously harm your health, you can ask for a fast (expedited) decision. This is only for Part D drugs that you have not already received. We must make expedited decisions within 24 hours after we get your doctor’s information.

If we approve your drug’s exception, the approval will be until the end of the plan year. To keep the exception in place, you must be enrolled in our plan, your doctor must continue to prescribe your drug, and your drug must be safe to treat your condition.

After we make a decision, we send you a letter telling you our decision. The letter has information on how to appeal

Redeterminations

If we deny your request for coverage of (or payment for) a drug, you, your doctor, or your representative can ask us for an appeal (redetermination). You have 60 days from the date of our denial letter to ask for a redetermination. You can complete the Request for Redetermination form, but you do not have to use it.

You can send the form or other written request by mail or fax to:

Phone: 
Contact Member Services

Fax:
1-844-273-2671

Mail:
Superior HealthPlan
Attn: Appeals and Grievances/Medicare Operations
7700 Forsyth Blvd
Saint Louis, MO 63105

Other Forms