PHP, California

Rachel Sakai
AHF Provider

How to Ask for a Coverage Decision

You can ask us to make a coverage decision, also known as a coverage determination, about your prescription drug benefits and coverage or about the amount we will pay for your drugs.  Here are the types of coverage decisions you can ask us to make:

  • If a drug is not covered in the way you would like it to be covered, you can ask for an exception.  When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved.  Types of exceptions include:
    • Asking us to cover a Part D drug that is not on the plan’s 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 get
    • Asking to pay a lower cost-sharing amount for a covered-drug
  • 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 formulary but we require you to get approval from us before we will cover it for you.

To ask that we make a coverage decision about the prescription drug or payment you need, contact Member Services by phone, fax, or letter.   You or your doctor can make your coverage decision request.   If you have someone asking for a coverage decision for you other than your doctor, you must submit an Appointment of Representative form authorizing this person to represent you.  We have a form you, your doctor, or appointed representative can complete that asks for information we need to make a coverage decision.  Download the Coverage Determination Request form, print a copy, complete and mail it to the address on the form or fax it to the number on the form.

If your health requires a quick response, you should ask us to make a “fast decision,” also known as an expedited determination.  You cannot ask for a fast coverage decision if you are asking us to pay you back for a drug you already bought.  You, your doctor or your representative can do this for you.

We will give you a decision within 72 hours after we receive your request, unless we have agreed to use the “fast” deadline, which is within 24 hours.  If your doctor tells us that your health requires a “fast decision,” we will automatically agree to give you a fast decision.

If you ask for a “fast decision” on your own, without a doctor’s support, we will decide whether you health requires that we give you a fast decision.  If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter that says so and we will use the standard deadline, which is within 72 hours.

If our answer is “yes” to part or all of what you requested, we must provide the coverage we have agreed to provide within 72 hours after we receive your request or doctor’s statement supporting your request for a standard decision or 24 hours after we receive your request or doctor’s statement supporting your request for a standard decision for a “fast” decision.  If you are asking us to pay you back for a drug you have already bought, we have 14 calendar days after we receive your request to make a decision.  If we say “yes” to your request that we reimburse you, we have to make payment to you within 30 calendar days after we receive your request.

If our answer is “no” to part or all of what you requested we will send you a written statement explaining why.  You decide if you want to make an appeal.  If you do, please read “Appealing a Decision We Made on a Prescription Service.”

For detailed, step-by-step information about requesting a prescription drug coverage decision, please see Chapter 9, Section 6 of the 2019 Evidence of Coverage, or contact Member Services.  You may also contact Member Services to check on the status of your coverage decision request.


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