Prescription Drug Determination Exceptions

Medicare Part D Prescription Drug Coverage Determinations & Exceptions

A coverage determination is a decision made by CHRISTUS Health Plan regarding payment, dosage limits prior authorization and other matters with prescription drugs. Coverage determinations can be requested if a member disagrees with:

  • Receipt or payment for a prescription drug that a member believes may be covered
  • A tiering or formulary exception
  • The amount that CHRISTUS Health Plan requires a member to pay for a Part D prescription drug
  • The limit on the quantity or dose of a requested drug
  • A requirement that a member try another drug before CHRISTUS Health Plan will pay for the requested drug
  • A decision on whether the member has or has not satisfied a prior authorization or other utilization management requirement

How to Request a Part D Coverage Determination or Exception

A member, their representative or a prescribing physician may request a coverage determination by filling out the Part D Coverage Determination Request Form. Complete the form and fax it to 1-877-327-3760 or mail it to:

Express Script
c/o Prior Authorization Dept.
PO Box 2858
Clinton, IA 52733-2858

Part D Coverage Determination & Exception Decisions

For requests for benefits that do not involve exceptions, the Plan will provide notice of its decision within 24 hours after receiving an expedited request or 72 hours after receiving a standard request.

For requests for benefits that involve exceptions, the adjudication timeframes do not begin until the member’s prescriber submits his or her supporting statement to the Plan for review.

For payment requests, including payment requests that involve exceptions, CHRISTUS Health Plan Generation will provide written notice of its decision (and make payment when appropriate) within 14 calendar days after receiving a request.

If CHRISTUS Health Plan Generation coverage determination is unfavorable, the decision will contain the information needed to file a request for appeal/ redetermination with the Plan.

H1189_MM143 pending approval
Last Updated: 2/23/17