Coverage Determinations

Back To For Members

Part D Coverage 

What is a coverage decision?

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. 

We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases, we might decide a drug is not covered or is no longer covered by Medicare for you. 

Here are examples of coverage decisions you ask us to make about your Part D drugs:

  • You ask us to make an exception, including:
    • Asking us to cover a Part D drug that is not on the plan’s List of Covered Drugs (Formulary)
    • Asking us to waive a restriction on the plan’s coverage for a drug (such as limits on the amount of the drug you can get)
    • Asking to pay a lower cost sharing amount for a covered drug on a higher cost sharing tier
  • You ask us whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on the plan’s List of Covered Drugs (Formulary) but we require you to get approval from us before we will cover it for you.)
    • Please note: If your pharmacy tells you that your prescription cannot be filled as written, the pharmacy will give you a written notice explaining how to contact us to ask for a coverage decision.
  • You ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment.

If you disagree with this coverage decision, please visit our Grievances & Appeals page for more information on the appeal process.

How to request coverage?

Request the type of coverage decision you want. Start by calling, writing, or faxing us to make your request. You, your representative, or your doctor (or other prescriber) can do this. You may call our Customer Care Center if you have questions about our coverage decision process.

Write

Banner Medicare Rx
Attn: Customer Care Center
5255 E Williams Circle, Ste 2050
Tucson, AZ 85711

Phone 

Customer Care Center: (844) 549-1859, TTY 711

Fax

(866) 849-0338

Denial of Coverage Request

If we deny your coverage request, you have the right to request an appeal. Requesting an appeal means asking us to reconsider – and possibly change – the decision we made.

Visit our Grievances & Appeals page for more information on the appeal process.

Visit our Appointment of Representative page for more information on appointing an individual to act as your representative.