Prescription Drug Coverage Determination
Request approval (determination or redetermination) for CarePlus to cover certain medications.
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When to request a drug coverage determination

Determination is required for certain 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. 

If your medication requires this step, you, your appointed representative or the prescriber will need to request and receive approval for CarePlus to cover it. If a request was denied, you may submit a request for redetermination (submit an appeal). 

How to request drug coverage determination

There are several ways to submit your request depending if it is submitted by your prescriber or by you or your representative.

Prescriber You or your representative

Your prescriber can call the following number or submit a request online.

866-315-7587
We are available Monday - Friday, 8 a.m. to 8 p.m.

If your prescriber calls this number, we can answer any questions and provide a coverage determination form specifically for the requested drug. Then your prescriber can submit the completed form by fax at: 800-310-9071

CarePlus partners with CoverMyMeds to provide real-time determinations for requests submitted online. Registration by your prescriber is required. Please use the information on this CoverMyMeds flyer  for quick and easy registration.

Complete the Coverage Determination Request Form in English or Spanish

This is a general form that is not specific to your drug. CarePlus Clinical Pharmacy Review may need to contact your prescriber for additional information before we can make a determination for the drug.

You or your representative may submit your request online, by fax, by mail or by calling Member Services. 

Complete the Coverage Determination Request Form in English or Spanish

You will need to submit supporting documents from your prescriber to help us determine if you medically need the requested medication. Your information will be sent to us securely.

Download a copy of the form below and fax or mail it to CarePlus:

English Prescription Drug Coverage Determination Request Form  

Spanish Prescription Drug Coverage Determination Request Form

You can also access Medicare’s Part D Coverage Determination Request Form on the CMS website.

Fax your form:
800-310-9071

Mail your form:
CarePlus Health Plans
Attention: CarePlus Clinical Pharmacy Review
P.O. Box 14601
Lexington, KY 40512

If a representative (other than you or your prescriber) submits the request for you, please provide a legal representation form with your request or make sure you have completed an Appointment of Representative Form. Otherwise we will not be able to process your request.
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Last Updated:

10/01/2025

What happens next?

  •  Timing

    We will let you know if the request was approved or denied no later than 72 hours for standard requests or 24 hours for expedited requests, once it has been received. For exceptions, the timeframe begins when we obtain your prescriber’s supporting statement. Your request will be expedited if we determine or if your prescriber tells us that your life, health or ability to regain maximum function may be seriously jeopardized by waiting for a standard decision.

  • If we determine your drug is not covered

    In some cases, CarePlus may deny your request for coverage of a prescription drug. If we deny all or part of your request, we will send you a detailed written explanation and instructions on how to appeal our decision if you disagree.

  • More information and data

    You can find detailed information in Chapter 9 of your CarePlus Evidence of Coverage (EOC) with regard to grievances, coverage determinations (including Medicare Part D exceptions) and the appeals process. Log in to MyCarePlus to view your plan’s EOC, or you may find all CarePlus EOC documents on our CarePlus Medicare Advantage Plan Details page.

    To obtain information on the aggregate number of grievances, coverage determinations (including Medicare Part D exceptions) and appeals filed with the plan, please call Member Services.