Medicare Part B or Medicare Part D Coverage Determination (B/D)

Depending on how this drug is used, it is covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it’s correctly covered by Medicare.

NOTE: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.

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How to appoint a representative to help you with a coverage determination

The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case. Download the Appointment of Representative form.

Both you and the person you have named as an authorized representative must sign the representative form, unless your representative is a lawyer. In that case, only your signature is needed. This statement must be sent to Physicians Health Choice, PO Box 690670, San Antonio TX 78269-0670. Or you can fax it to the Physicians Health Choice Medicare Plans – AOR at 1-813-712-8296. If your prescribing doctor calls on your behalf, no representative form is required.

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How to request a coverage determination (including benefit exceptions)

You can ask the plan to make the following exceptions to the plan’s coverage rules:

• Coverage for a drug not on the formulary. If an exception is approved, you would get the prescription drug at the Tier 4 copay level.
• More coverage for your drug(s). If your generic or brand drug is in Tier 4, you can ask that the plan cover it as a Tier 3 generic or brand drug, so long as there is a generic or brand drug in Tier 3 for treating the same condition that the requested generic or brand Tier 4 drug is being used to treat. If your generic or brand drug is inTier 3, you can ask that the plan cover it as a Tier 2 generic or brand drug, so long as there is a generic or brand drug in Tier 2 for treating the same condition that the requested generic or brand Tier 3 drug is being used to treat. This would lower the amount you must pay for your drug. Likewise, you can ask the plan to cover a Tier 2 generic drug at the Tier 1 copay level so long as there is a generic drug in Tier 1 for treating the same condition that the requested Tier 2 generic drug is being used to treat. Note: If the plan grants your request to cover a drug that is not on the formulary, you may not ask the plan to provide a higher level of coverage for the drug.

Generally, your request for an exception will be approved only if the alternative drugs included on the plan’s formulary or the lower-tiered drug would not be as effective in treating your condition or would cause you to have adverse medical effects.

Call the Physicians Health Choice Customer Service number to request a coverage determination.
When requesting a formulary or tiering exception, a statement from your doctor supporting your request is required. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor’s supporting statement (if required).

You can request an expedited (fast) coverage determination if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor’s supporting statement.

If you are a continuing member in the plan, you may notice that a medication you currently take is either not on the 2012 formulary or its cost-sharing or coverage is limited in the upcoming year. For coverage and exception requests received by December 15, 2011 and approved, the plan will cover the drug as of January 1, 2012. For coverage requests started on or after December 16, 2011, normal timeframes for resolution apply: you will receive an answer within 24 hours for urgent requests and 72 hours for all other requests. If your request is still in process on January 1, 2012, you may receive a temporary supply of the drug for your current plan cost-sharing until your request is answered.

To initiate a coverage determination request, please contact Physicians Health Choice.

Have the following information ready when you call:

• Member name
• Member date of birth
• Medicare Part D Member ID number
• Name of the medication
• Physician's phone number
• Physician fax number (if available)

You may also request a coverage determination/exception by logging on to www.prescriptionsolutions.com and submitting a request. If you are a new user with Prescription Solutions, you will need to register before you can access the Prior Authorization request tool. Once you have registered, you will find the Prior Authorization tool under the Health Tools Menu. Once your request has been submitted, we will attempt to contact your prescriber to get a supporting statement and/or additional clinical information needed to make a decision.

Download this form to request an exception:

• Medicare Part D Coverage Determination Request Form (PDF) – for use by members and providers

This is a CMS-model exception and prior authorization request form developed specifically for use by all Medicare Part D prescribing physicians or members. You may use this form or the Prior Authorization Request Forms listed below. The Prior Authorization Department will accept both request forms.

• 2012 Prior Authorization Criteria (PDF) - For members of the Physicians Health Choice Total (HMO) plan in Aransas, Kleberg, Nueces, San Patricio, Hays, Travis, Williamson, El Paso, Cameron, Hidalgo, Willacy Counties, Texas; members of the Physicians Health Choice Select (HMO SNP) plan in Aransas, Kleberg, Nueces, San Patricio, Hays, Travis, Williamson, El Paso, Cameron, Hidalgo, Willacy Counties, Texas
• Medication Prior Authorization Request Form (PDF)
• Specialty Pharmacy Prior Authorization Request Forms

To initiate a request, providers may contact Physicians Health Choice or fax to 1-813-712-8296. The plan’s decision on your exception request will be provided to you by telephone or mail. In addition, the initiator of the request will be notified by telephone or fax.

To inquire about the status of a coverage determination, contact Physicians Health Choice.

For more information, see your plan’s Evidence of Coverage.

Note: Existing plan members who have already completed the coverage determination process for their medications in 2011 are not required to complete this process again.

To obtain an aggregate number of the plan's grievances, appeals and exceptions please contact Physicians Health Choice.

The following information about your Medicare Part D Drug Benefit is available upon request:

• Information on the procedures used to control utilization of services and expenditures.
• Information on the number and disposition in the aggregate of appeals and quality of care grievances filed by those enrolled in the plan.
• A summary of the compensation method used for physicians and other health care providers.
• A description of our financial condition, including a summary of the most recently audited statement.

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