To get a drug coverage determination, you, your 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 CarePlus Pharmacy Utilization Management Unit 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 CarePlus Pharmacy Utilization Management Unit 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 our CarePlus Pharmacy Utilization Management Unit 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 CarePlus Pharmacy Utilization Management Unit at the number listed above.

  If you would like to make the coverage determination request yourself, you or your representative must contact us in one of the following ways:

• 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 after hours, Saturdays, Sundays, and holidays, and we will return your call within one business day
• 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 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: CarePlus Pharmacy Utilization Management Unit

  PO Box 277810

  Miramar, FL 33027

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 one business day.

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 (appeal) by following the instructions provided on the coverage determination notice or as described below.

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

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

To request a drug coverage redetermination, you, your 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 Online Form. It is fast, easy, and secure. You will 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 to us 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 Online Form
  English (link opens in new window)  | Spanish (link opens in new window) 

Fax or mail – You may download a copy of the Medicare Part D Redetermination Request 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 Department

PO Box 277810

Miramar, FL 33027

Be sure to submit all supporting information for your appeal. You or your prescribing physician or other prescriber can send this 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 representative, your prescribing physician or other prescriber may call Member Services at the number listed above.

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 after hours, Saturdays, Sundays, and holidays and we will return your call within one business day.