Part D Coverage Decision

What is a coverage decision?

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your drugs. A coverage decision is often called an "initial determination" or "initial decision." When the coverage decision is about your Part D drugs, the initial determination is called a "coverage determination."

Here are examples of coverage decisions you ask us to make about your Part D drugs:

• You ask us to make an exception, including:
  • Asking us to cover a Part D drug that is not on the plan's List of Covered Drugs
  • Asking us to waive a restriction on the plan's coverage for a drug (such as limits on the amount of the drug you can get)
  • Asking to pay a lower cost-sharing amount for a covered non-preferred drug
• You ask us 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 List of Covered Drugs but we require you to get approval from us before we will cover it for you.)
• You ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment.   Click here for the KelseyCare Advantage/Catalyst Rx Direct Member Reimbursement Form   PDF
• If you disagree with a coverage decision we have made, you can appeal our decision. See the bottom of this page for more information.

What is an exception?

If a drug is not covered in the way you would like it to be covered, you can ask the plan to make an "exception." An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request. Here are three examples of exceptions that you or your doctor or other prescriber can ask us to make:

• Covering a Part D drug for you that is not on our plan's List of Covered Drugs (Formulary).
• Removing a restriction on the plan's coverage for a covered drug.
• Changing coverage of a drug to a lower cost-sharing tier.

What is important about asking for exceptions?

Your doctor must tell us the medical reasons

Your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception.

Typically, our Drug List includes more than one drug for treating a particular condition. These different possibilities are called "alternative" drugs. If an alternative drug would be just as effective as the drug you are requesting and would not cause more side effects or other health problems, we will generally not approve your request for an exception.

Your physician can submit the request using the Physician Coverage Determination Request Form. The form asks your physician for information regarding your diagnosis, what other drug(s), if any, has been prescribed for the diagnosis and why it has not worked, and other questions. Your physician should send the completed form to:

KelseyCare Advantage
c/o Catalyst Rx PA Team
1650 Spring Gate, Suite 100
Las Vegas, NV 89134

Or by fax to: 1-888-852-1832

Your physician can also provide an oral supporting statement by calling 1-888-869-4600. Click here for the KelseyCareAdvantage/Catalyst Authorization form for Coverage Determination requests  PDF. This form can be used by a member or physician.

Our plan can say yes or no to your request

• If we approve your request for an exception, our approval usually is valid until the end of the plan year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.
• If we say no to your request for an exception, you can ask for a review of our decision by making an appeal.

What is an appeal?

If our plan says no, you have the right to request an appeal. Requesting an appeal means asking us to reconsider – and possibly change – the decision we made.  An appeal to the plan about a Part D drug coverage decision is called a plan “redetermination.”  Please refer to your evidence of coverage Chapter 9 that discusses the 5 levels of appeals.  When our plan is reviewing your appeal, we take another careful look at all of the information about your coverage request. We check to see if we were being fair and following all the rules when we said no to your request. We may contact you or your doctor or other prescriber to get more information.

If we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it.  If we are using the standard deadlines, we must give you our answer within 7 calendar days after we receive your appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so.

What is a grievance (compliant)?

The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Here are examples of the kinds of problems handled by the complaint process.

• Do you believe that someone did not respect to privacy or shared information about you that you feel should be confidential?
• Has someone been rude or disrespectful to you?
• Do you feel waiting too long on the phone or when getting a prescription?
• If you have asked us to give you a “fast response” for a coverage decision or an appeal, and we have said we will not, you can make a compliant.
• If you believe our plan is not meeting deadlines for giving you a coverage decision or an answer to an appeal you have made , you can make a compliant.

What is not a grievance (compliant)?

If your problem is about decisions related to benefits, coverage, or payment, then you will need to use the process for coverage decisions and appeals.

How to contact us when you are making an appeal or a compliant about your Part D prescription drugs:

1-866-535-8343 (TTY/TDD: 866-302-9336)

Hours of Operation: 8:00 AM – 6:00 PM CST, Monday – Friday.

TTY:  1-866-302-9336  This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.  Calls to this number are free. 

FAX:  713-442-9536

WRITE: 
KelseyCare Advantage
Attn:  Member Services
P.O. Box 300427
Houston, TX 77230  

You can ask someone to act on your behalf.

If you want to, you can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal.

• There may be someone who is already legally authorized to act as your representative under State law.
• If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Member Services toll free at 1-866-535-8343 (TTY/TTD 866-302-9336), 8 a.m. to 8 p.m. Central time, Monday – Sunday and ask for the form to give that person permission to act on your behalf. The form must be signed by you and by the person who you would like to act on your behalf. You must give our plan a copy of the signed form.