Coverage Determination and Redetermination

Drug Coverage Determination and Redetermination

Some Prescription Drugs Require Authorization

Certain drugs require a coverage determination. If your drug requires this step, you, your appointed representative, or your prescribing physician or other prescriber will need to request and receive approval in order for CarePlus to cover your drug. If you have already received an unfavorable drug determination, you may submit a request for redetermination.

Drug Coverage Determination

Why is a drug coverage determination required?

CarePlus has placed this requirement on selected high-risk or high-cost medications. We want to make sure these medications do not interfere with others you take or add to your costs unnecessarily. Coverage determination criteria are established by our Pharmacy and Therapeutics Committee with input from providers, manufacturers, peer-reviewed literature, research, and other experts.

Coverage Determination Request

To get a drug coverage determination, you, your appointed representative, or your prescribing physician or other prescriber can contact CarePlus in one of the following ways:

  • Ask your prescribing physician or other prescriber to submit the request for you
    Your prescribing physician or other prescriber may call our Pharmacy Coverage Determination Review team at 1-866-315-7587 and make a coverage determination request over the phone. We are available to take your provider’s call Monday – Friday from 8 a.m. to 8 p.m.

    Alternatively, your prescribing physician or other prescriber can submit a coverage determination request form for you. Your physician may call the Pharmacy Coverage Determination Review team at the number provided above and request a coverage determination form specifically designed for the drug that is being requested, and submit the completed form to us by fax at 1-800-310-9071. This form will include specific questions to ensure all required information is obtained for the review. Your physician can also submit the request for you online by filling out the Coverage Determination Request Form (English (link opens in new window)  | Spanish (link opens in new window) ), which is a general form. This form may require for the Pharmacy Coverage Determination Review team to contact your physician to obtain additional information that is specific to the drug that is being requested.

    For process or status questions, your prescribing physician or other prescriber may call the Pharmacy Coverage Determination Review team at the number listed above.

  • Submit your request online - If you prefer, you can complete the Coverage Determination Request Form (English (link opens in new window)  | Spanish (link opens in new window) ) yourself, but you will need to send us supporting documentation from the prescribing physician or other prescriber to show medical need. Your information will be sent to us securely. Before completing the form, you may want to view our accepted file types (link opens in new window) .

  • Fax or mail the form - You can download a copy of the form below and fax or mail it to CarePlus.

    PDFCoverage Determination Request Form - English(link opens in new window) 

    PDFCoverage Determination Request Form - Spanish(link opens in new window) 

    Fax number: 1-800-310-9071

    Mailing address:
    CarePlus Health Plans
    Attention: Pharmacy Coverage Determination Review
    11430 NW 20th Street, Suite 300
    Miami, FL 33172

Note: You can also access the Drug Determination Request Form at the CMS part D webpage link below:

PDFPart D Coverage Determination Request Form(link opens in new window)  (for use by enrollees and providers)

If you have any questions, please contact Member Services at 1-800-794-5907 from 8 a.m. to 8 p.m. 7 days a week. From February 15 to September 30th, we are open Monday – Friday from 8 a.m. to 8 p.m. TTY users should call 711.

Drug Coverage Redetermination

How to appeal an unfavorable drug coverage determination

If you have received an unfavorable drug determination, you may submit a request for redetermination. You may use the Medicare Part D Redetermination Request form to appeal your unfavorable coverage determinations. Redeterminations can be requested because of unfavorable formulary exceptions, coverage rule exceptions, or tiering exceptions.

PDFHow to Appeal - English(link opens in new window) 

PDFHow to Appeal - Spanish(link opens in new window) 

Medicare Part D Redetermination Request Form

To request a drug coverage redetermination, you, your appointed representative, your prescribing physician, or other prescriber can contact CarePlus in one of these ways:

  • Submit your request online – Complete the Medicare Part D Redetermination Request Form. It's fast, easy, and secure. You'll need the following:

    1. Your prescription drug information.
    2. The reason you are appealing the denial.
    3. Any clinical rationale provided to you by your prescribing physician or other prescriber. You may add this as an attachment in the online form or fax it to us at 1-800-956-4288.
    4. The prescribing physician or other prescriber’s information.

    Before completing the form, you may want to view our accepted file types (link opens in new window) .

    Medicare Part D Redetermination Request Form
    English (link opens in new window)  | Spanish (link opens in new window) 

  • Fax or mail the form – If you would prefer, you can download a copy of the form below and fax or mail it to CarePlus.

    PDFMedicare Part D Redetermination Request Form - English(link opens in new window) 

    PDFMedicare Part D Redetermination Request Form - Spanish(link opens in new window) 

    Fax number: 1-800-956-4288

    Mailing address:
    CarePlus Health Plans
    Grievance and Appeals department
    11430 NW 20th Street, Suite 300
    Miami, FL 33172

  • If you have any questions, please contact Member Services at 1-800-794-5907; from 8 a.m. to 8 p.m., 7 days a week. From February 15th to September 30th, we are open Monday-Friday from 8 a.m. to 8 p.m. TTY users should call 711.

    Be sure to provide additional supporting documentation for your appeal. This information may be sent by you or your prescribing physician or other prescriber by fax to 1-800-956-4288.

    Once the request is received, CarePlus Health Plans must make a decision and provide written notice of our decision within 7 calendar days for standard requests and within 72 hours for expedited requests. For process or status questions, your prescribing physician or other prescriber may call the Grievance and Appeals department at the number listed above.

How to Appoint a Representative

To consider a Part D coverage determination or redetermination request from someone other than you (the member), your prescribing physician, or other prescriber, we must have authorization. You may appoint any individual as your representative by sending us an Appointment of Representative form signed by both you and the representative. A representative who is appointed by the court or who is acting in accordance with state law may also file a request for you after sending us the legal representative form. You will not need to complete an Appointment of Representative Form if you provide an equivalent written notice or other legal representation document with your request.

Appointment of Representative Form

PDFAppointment of Representative Form - English(link opens in new window) 

PDFAppointment of Representative Form - Spanish(link opens in new window) 

Instructions on how to Appoint a Representative

PDFHow to Appoint a Representative - English(link opens in new window) 

PDFHow to Appoint a Representative - Spanish(link opens in new window) 

You also can get the Appointment of Representative form (link opens in new window)  on CMS's website.

If you have any questions, please contact Member Services at 1-800-794-5907; from 8 a.m. to 8 p.m., 7 days a week. From February 15th to September 30th, we are open Monday – Friday from 8 a.m. to 8 p.m. TTY users should call 711.

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