Coverage Decisions and Part D Coverage Determinations

Coverage Decisions for Health Care

A coverage decision is a decision we make about:

  • Your health care products and services coverage or
  • About the amount we will pay for your medical services or medical drugs.

For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from the doctor or if your network doctor refers you to a medical specialist.

You can also contact us and ask for a coverage decision if your doctor:

  • Is unsure if we will cover a health care product or service or
  • Refuses to provide medical care you think that you need.

If you want to know if we will cover a health care product or service before you receive it, you can ask us to make a coverage decision for you. We are making a coverage decision for you when we decide what is covered for you and how much we pay. In some cases we might decide a service is not covered or is no longer covered by Medicare.

If you disagree with this coverage decision, you can request an appeal.

For a standard decision:

  • We will give you our answer within 14 days of receiving your request.
  • We can take up to 14 more days ("an extended time period") for certain issues. If we decide to take extra days to make the decision, we will tell you in writing. If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days.

When you file a fast complaint, we will give you an answer to your complaint within 24 hours. If we do not give you our answer within 14 days (or if there is an extended time period, by the end of that period), you have the right to appeal.

If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 14 days after we received your request. If we extended the time needed to make our decision, we will provide the coverage by the end of that extended period. If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

You can ask our plan to make a coverage decision on the medical care you are requesting. Based on your health, if you need a quick response, you should ask us to make a "fast decision."

To get a fast decision, you must meet two requirements:

  • You can get a fast decision only if you are asking for coverage for health care you have not yet received. You cannot get a fast decision if your request is about payment for medical care you have already received.
  • You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.

If your doctor tells us that because of your health the request needs a "fast decision", we will automatically agree to give you a fast decision. If you ask for a "fast decision" on your own, without your doctor's support, our plan will decide if your 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 (and we will use the standard deadlines instead).

This letter will tell you that if your doctor asks for the fast decision, we will automatically give a fast decision. The letter will also tell how you can file a "fast complaint" about our decision to give you a standard decision instead of the fast decision you asked for.

A fast decision means we will answer within 72 hours. However, we can take up to 14 more calendar days if we find that some information that may benefit you is missing, or if you need time to get information to us for the review. If we decide to take extra days, we will tell you in writing. If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days.

Coverage decisions can be requested by mail, by phone, by fax to: 

EmblemHealth Medicare HMO
ATTN: Utilization Management
55 Water Street
New York, NY 10041-8190
Phone: 1-877-344-7364
TTY: 711
Fax: 1-866-215-2928

Part D Drug Coverage Determinations

A coverage determination is a decision by EmblemHealth and it can include the following:

  • To determine coverage for a Part D eligible drug not on EmblemHealth's formulary (list of covered drugs).
  • To determine approval for:
    • A prior authorization (that you will need to get approval from your plan before you fill your certain prescriptions),
    • Step therapy (you may need to try a different or more common drug first) or
    • Quantity limit request.
  • To determine approval for tiering (a drug’s level based on cost) exception request.

Coverage determinations include EmblemHealth’s decision on a member’s exception request.

Members may ask us for an exception (change a ruling):

  • To a plan’s tiered cost-sharing (you and your insurance company share the costs of some of the drugs that your plan covers based on the drug’s level) or
  • To cover a drug that is not on our list of covered drugs.

For an exception to be reviewed:

  • The doctor must give supporting documents that the drug on our list of covered drugs would not be as useful (or has been not been working as well) and/or
  • The drug may have a negative effect.

Note that certain high cost drugs may not be eligible for the exception process. All drugs approved under the exception process must meet the meaning of a Part D drug. Also, a provider’s statement does not necessarily mean it will be approved.

A member, his or her representative, or the member’s prescribing doctor or other prescriber, may ask for EmblemHealth to expedite a coverage determination when the member or their doctor or other prescriber believes that waiting for a decision under the standard time frame may place the member’s life, health or ability to regain maximum function in serious jeopardy.

You can request a coverage determination by mail, by phone, by fax or by email:

EmblemHealth Medicare HMO or EmblemHealth Medicare PDP
Pharmacy Services
55 Water Street
New York, NY 10041-8190
Phone: 1-877-444-7097
TTY: 711
Fax: 1-877-300-9695

Email: PartDCoverageDeterminations@emblemhealth.com

For requests for standard coverage determinations:

  • We will tell the member (and prescribing doctor or other doctor as needed) of the determination as quickly as possible.
  • This will be no later than 72 hours after receipt of the request for the coverage determination.
  • For an exceptions request, no later than 72 hours of receiving the doctor’s supporting statement (if one is provided) is received.

For requests for expedited coverage determinations:

  • A written notice of the determination will be provided by EmblemHealth to the member (and prescribing doctor or other doctor as needed) of the determination within 24 hours of the date of the request or
  • When the doctor’s supporting statement (if one is provided) is received.

If the request to expedite the decision is granted EmblemHealth will give notice to the member (and prescribing doctor or other doctor as needed):

  • Within 24 hours of receiving the request (or for an exceptions request in which a non-formulary drug is requested) or
  • Within 24 hours of receiving the doctor’s supporting statement.

If the request to expedite is denied, EmblemHealth will make the determination within 72 hours of request of doctor’s statement. We will give prompt oral notice of the denial of the expedited request which explains the following:

  1. EmblemHealth’s standard process.
  2. Informs the member of the right to file expedited grievance.
  3. Informs the member of the right to resubmit the request with a doctor’s supporting documentation and
  4. Gives instructions about EmblemHealth’s grievance process and its time frames.

We will also send a written notice within three calendar days after oral notice of the denial. Note that expedited coverage determinations are not allowed for payment requests.

Medicare Prescription Drug Coverage Determination Request Form

To determine if you may need to request a coverage determination or exception, please refer to EmblemHealth’s Part D Formulary.

Nondiscrimination Policy

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