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 (appeal).

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.

Drug 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 prescriber’s call Monday – Friday from 8 a.m. to 8 p.m.

    Your prescribing physician or other prescriber can submit a coverage determination request form for you. Your prescriber 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 also can 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 our Pharmacy Coverage Determination Review team to contact your prescriber to obtain additional information specific to the drug 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.

    PDFPrescription Drug Coverage Determination Request Form - English(link opens in new window) 

    PDFPrescription Drug Coverage 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 also can 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 call Member Services at 1-800-794-5907; TTY: 711. From October 1 - March 31, we are open 7 days a week; 8 a.m. to 8 p.m. From April 1 - September 30, we are open Monday - Friday, 8 a.m. to 8 p.m. You may always leave a voicemail message after hours, Saturdays, Sundays, and holidays and we will return your call within 1 business day.

Drug Coverage Redetermination Request

How to appeal an unfavorable drug coverage determination

If you have received an unfavorable drug determination (that is, CarePlus has denied your request for coverage of or payment for a prescription) you may submit a request for redetermination. You may use the Medicare Part D Redetermination Request form to appeal your unfavorable coverage determinations.

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 is fast, easy, and secure. You'll need the following:

    • Your prescription drug information
    • The reason you are appealing the denial
    • The prescribing physician or other prescriber’s information
    • 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 send it by fax to us at 1-800-956-4288

    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 – 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

    Attention: Grievance and Appeals

    11430 NW 20th Street, Suite 300

    Miami, FL 33172

  • If you have any questions, please call Member Services at 1-800-794-5907; TTY: 711. From October 1 - March 31, we are open 7 days a week; 8 a.m. to 8 p.m. From April 1 - September 30, we are open Monday - Friday, 8 a.m. to 8 p.m. You may always leave a voicemail message after hours, Saturdays, Sundays, and holidays and we will return your call within 1 business day.

    Be sure to provide additional supporting documentation for your appeal. You or your prescribing physician or other prescriber can send the form and information to us by fax at 1-800-956-4288.

    Once we receive the request, we must make a decision and provide written notice of our decision within 14 calendar days for payment requests, 7 calendar days for standard requests (for drug benefits) and 72 hours for expedited requests (for drug benefits). For process or status questions, you, your appointed representative, your prescribing physician or other prescriber may call the Member Services 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 that you and the representative sign. A representative who is appointed by the court or who is acting in accordance with state law also can file a request for you, after sending us the proper legal documentation. 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 the CMS website.

If you have any questions, please call Member Services at 1-800-794-5907; TTY: 711. From October 1 - March 31, we are open 7 days a week; 8 a.m. to 8 p.m. From April 1 - September 30, we are open Monday - Friday, 8 a.m. to 8 p.m. You may always leave a voicemail message after hours, Saturdays, Sundays, and holidays and we will return your call within 1 business day.