Prescription Drug Coverage Request
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Read More InfoPart D Coverage Determination Process
A coverage determination is an initial coverage decision about your Part D prescription drugs.
Here are examples of coverage decisions you can ask us to make:
- You can ask whether a prescription 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 but we require you to get approval from us before we will cover it for you.)
- You can ask us to pay for a prescription drug you already bought.
- You can ask us for an exception if a prescription drug is not covered in the way you would like it to be covered.
Requesting an Exception:
Here are examples of exception requests:
- Asking for coverage of a prescription drug not on the drug list.
- Asking to pay a lower cost-sharing amount for a covered, non-preferred prescription drug.
- Asking us to remove the limits and restrictions on the plan's coverage for a drug such as the case when we have a limit on the amount of a particular prescription drug that will be covered.
Important Information to Know About Asking for Exceptions
When you ask for an exception your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception. Include this medical information from your doctor or other prescriber when you ask for the exception.
How to Request a Coverage Determination or Exception
You (or your representative or your doctor or other prescriber) may use one of the forms below to submit your request for a Part D Coverage Determination or Exception or you may request a determination or exception orally by calling the number below. Your doctor or other prescriber does not need to be an appointed representative to request a standard or expedited coverage determination.
For Member Use:
For Provider Use:
Provider Coverage Determination/Exception Form
You (or your representative or your doctor or other prescriber) can start or check the status of your Part D Coverage Determination or Exception request by using the contact information below.
Fax
(602) 674-6652
(888) 887-9982
Phone
AAHP Member Service
(602) 824-3900 or (888)-864-1114
Seven days a week, 8 am to 8 pm
For Hearing Impaired Assistance:
TTY/TDD (800) 842-4681 to access the Arizona Relay System
Mail:
Abrazo Advantage Health Plan
Prior Authorization Department
7878 North 16th Street, Suite 105
Phoenix, AZ 85020
If your request for a coverage determination is denied, you will receive a Notice of Denial of Medicare Coverage. If you do not agree with AAHP's determination, you have the right to file an appeal.
Click here to go to AAHP's Grievance & Appeals web page.
To find out more details about the Part D Coverage Determination process refer to your Evidence of Coverage booklet, Chapter 9, Section 6. Or call our Member Services at the number(s) listed above.
H5985_502-2011 CMS Approved 03022012