You can ask Health New England Medicare Advantage to make a coverage determination or exception to our coverage rules. There are several type of exceptions that you can ask us to make. You can ask us to:
- Cover your drug even if it is not on our formulary.
- Waive coverage restrictions or limits on your drug. For example, for certain drugs, HNE Medicare Advantage limits the amount of the drug that we will cover. If you drug has a quantity limit, you can ask us to waive the limit and cover more.
- Provide a higher level of coverage for your drug. If your drug is contained in our non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier subject to the tiering exceptions process instead. This would lower the amount you must pay for your drug. (Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the specialty tier.)
Generally, Health New England Medicare Advantage will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request.
We generally must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement. You can request an expedited (fast) exception 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 get your prescriber’s or prescribing physician’s supporting statement.
To submit a request or check on the status of a request for a coverage determination or redetermination, use the “Online Requests” button above. Usually, your prescriber will submit a request on your behalf. You or your prescriber may also use the NPS Coverage Determination Request Form or CMS Medicare Part D Coverage Determination Request Form.
You, your prescriber, treating provider, or authorized representative may contact us by mail, fax, or telephone at one of the addresses, fax, or telephone numbers provided on the Initial Decisions, Appeals, and Grievances page.