Exceptions, Appeals & Grievances
Your Part D Prescription Drugs: Coverage Decisions, Exceptions
What is a coverage determination?
A coverage determination is a decision Commonwealth Care Alliance makes about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. 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 reasons why you need the exception approved. We will then consider your request.
How to obtain coverage determination or exception
You, your physician, or your appointed representative may file a coverage determination, including an exception, by:
Mail: Navitus Health Solutions
P.O. Box 1039
Appleton, WI 54912-1039
- Download the Model Drug Coverage Determination Form (pdf)
- Download the Request for Redetermination of Medicare Prescription Drug Denial Form (pdf)
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Last Updated 10/28/2016