Coverage Determinations, Exceptions and Redeterminations
Under the Trillium Advantage Part D prescription drug benefit program, a member can ask for a coverage determination regarding the drug benefits they are entitled to receive. A coverage determination is a decision our plan makes about whether or not to provide or pay for a Part D drug or what the member’s cost is for a Part D prescription drug. This includes asking our plan to make an exception to the way a drug is covered.
A coverage determination is any decision made by the plan regarding:
- Receipt of, or payment for, a prescription drug that a member believes may be covered;
- A tiering or formulary exception request;
- The amount that the plan requires a member to pay for a Part D prescription drug and the member disagrees with the plan;
- A limit on the quantity (or dose) of a requested drug and the member disagrees with the requirement or dosage limitation; and
- A decision whether a member has, or has not, satisfied a prior authorization or other utilization management requirement.
A member, a member’s representative, or a member’s prescriber may request a coverage determination, including an exception, by completing and signing the form listed below. For faster processing, the form can be faxed to 1-541-984-5686. The form can also be sent by mail to:
Catamaran/OptumRx PA Department
P.O. Box 5252
Lisle, IL 60532
In addition, a member, a member’s representative, or a member’s prescriber can request a coverage determination by phone at 1-855-529-1514. If the member believes waiting 72 hours for a standard decision could seriously harm their life, health, or ability to regain maximum function, they can ask for an expedited decision. If the prescriber indicates that waiting 72 hours could seriously harm the member’s health, a decision will be made within 24 hours after receipt from the prescriber of a supporting statement.
Once Trillium Advantage approves an exception, we cannot require a member to request approval for a refill or new prescription to continue using the Part D prescription drug approved under the exceptions process for the remainder of the plan year. In order to keep the exception in place for the whole year, the member must remain enrolled in Trillium Advantage, the member’s physician or other prescriber must continue to prescribe the drug, and the drug must be safe for treating the member’s condition.
When a decision is made, the member will receive a written notification detailing the outcome including member appeal rights for any requests that have been denied.
If Trillium Advantage changes the formulary or the cost-sharing status of a drug during the plan year, we will give written notice to affected enrollees at least 60 days in advance of the change becoming effective. If Trillium Advantage is unable to give a 60-day advance notice, we will supply the drug affected by the change and give written notice at the time of refill. For process or status questions, you can contact Member Services at 1-844-867-1156 TTY users call 711. If your provider has process or status questions, they can contact us at 1-844-867-1156.
If you or your provider would like to request a coverage determination:
*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).
Medicare Hospice Form (for provider use only):
If we deny your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You, your prescriber, or your representative may ask us for an appeal. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination. You may request a redetermination by completing the Request for Redetermination of Medicare Prescription Drug Denial form (for you applicable plan type below) but you are not required to use this form. You can send us the form, or other written request, by mail or fax to:
Attn: Appeals and Grievances, Medicare Operations
7700 Forsyth Blvd
Saint Louis, MO 63015
Expedited appeal requests can be made by phone at 1-844-867-1156 or TTY: 711.
If you or your prescriber believe that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 7 days could seriously harm your health, we will automatically give you a decision within 72 hours. If you do not obtain your prescriber’s support for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.
If you or your provider would like to request a redetermination:
If you or your provider would like to request a reconsideration:
Request for Reconsideration of Prescription Drug Denial Dual (HMO SNP)
Request for Reconsideration of Prescription Drug Denial Pioneer Rx (PPO)
Request for Reconsideration of Prescription Drug Denial TLC ISNP (HMO SNP)
Request for Reconsideration of Prescription Drug Denial TLC Community ISNP (HMO SNP)
Last Updated: 09302016