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Coverage Determinations and Redeterminations for Drugs

A coverage determination is a decision about whether a drug prescribed for you will be covered by us and the amount you’ll need to pay. If a drug is not covered or there are restrictions or limits on a drug, you may request a coverage determination.

You can ask us to cover:

  • a drug that is not on our list of drugs.
  • a drug that requires prior approval.
  • a drug at a lower cost sharing tier, as long as the drug is not on the specialty tier (Tier 5).
  • a higher quantity or dose of a drug.

You, your representative, or your doctor may submit a coverage determination request by fax, mail or phone. You must include your doctor’s statement explaining why your drug is necessary for your condition. Within 72 hours after we receive your doctor’s statement, we must make our decision and respond. If we deny your request you can appeal our decision. Information on how to file an appeal will be included in the denial notice.

Generally, we will only approve your request for an exception if the alternative drug is included on our formulary, the lower cost-sharing drug or additional restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You also can contact Member Services.

Drug Coverage Determination Form By mail:  By fax: By phone:

Drug Coverage Determination Form (HMO) - English (PDF)

Drug Coverage Determination Form (HMO) - Spanish (PDF)

Drug Coverage Determination Form (HMO SNP) - English (PDF)

Drug Coverage Determination Form (HMO SNP) - Spanish (PDF)


Allwell – Attn: Medicare Part D Prior Authorization Dept.  
P.O. Box 419069
Rancho Cordova, CA 95741-9069                                                                                                                                                                    
1-866-226-1093                                                                                                                                                                 HMO:
1-855-766-1452 (TTY: 711);

HMO SNP:
1-833-298-3361 (TTY: 711)                                                                                                                                                  

For Doctors and Other Prescribers ONLY call: 1-800-867-6564 (TTY:711)

Standard and Fast Decisions

If you or your doctor believe that waiting 72 hours for a standard decision could seriously harm your health, you can ask for a fast (expedited) decision. This applies only to requests for Part D drugs that you have not already received. We must make expedited decisions within 24 hours after we get your doctor’s supporting statement.

If we approve your drug’s exception, the approval continues until the end of the plan year. To keep the exception in place for the plan year, you must remain enrolled in our plan, your doctor must continue to prescribe your drug, and your drug must be safe for treating your condition.

After we make a decision, we send you a notice explaining our decision. The notice includes information on how to appeal a denied request.

Redeterminations

If we deny your request for coverage of (or payment for) a drug, you, your doctor, or your representative may ask us for a redetermination (appeal). You have 60 days from the date of our denial notice to request a redetermination. You can complete the Redetermination form, but you are not required to use it. You can send the form, or other written request, by mail or fax to:

Allwell
Attn: Appeals and Grievances, Medicare Operations
7700 Forsyth Blvd
Saint Louis, MO 63105
Fax: 1-844-273-2671

Expedited appeal requests can be made by phone at:

  • HMO: 1-855-766-1452 (TTY: 711) 
  • HMO SNP: 1-833-298-3361 (TTY: 711)

If you or your doctor states that waiting 7 days for a standard decision could seriously harm your health or ability to regain maximum function, you can ask for a fast (expedited) decision. If your doctor states this, we will automatically give you a decision within 72 hours. If we do not receive your doctor’s supporting statement for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

What if I have an urgent request?

If the member believes waiting 72 hours for a standard decision could seriously harm their life, health, or ability to regain maximum function, they can ask for an expedited decision. If the prescriber indicates that waiting 72 hours could seriously harm the member’s health, a decision will be made within 24 hours after receipt from the prescriber of a supporting statement.

Once Allwell approves an exception, we cannot require a member to request approval for a refill or new prescription to continue using the Part D prescription drug approved under the exceptions process for the remainder of the plan year. In order to keep the exception in place for the whole year, the member must remain enrolled in the Allwell plan, the member’s physician or other prescriber must continue to prescribe the drug, and the drug must be safe for treating the member’s condition.

When a decision is made, the member will receive a written notification detailing the outcome including member appeal rights for any requests that have been denied.

If Allwell changes its formulary or the cost-sharing status of a drug during the plan year, we will give written notice to affected enrollees at least 60 days in advance of the change becoming effective. If Allwell is unable to give a 60-day advance notice, we will supply the drug affected by the change and give written notice at the time of refill. For process or status questions, you or your provider can call us to speak to someone in Member Services.

Redeterminations

If we deny your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You, your prescriber, or your representative may ask us for an appeal. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination. You may request a redetermination by completing the Request for Redetermination of Medicare Prescription Drug Denial form but you are not required to use this form. You can send us the form, or other written request, by mail or fax to:

Centene Corporation
Attn: Appeals and Grievances, Medicare Operations
7700 Forsyth Blvd
Saint Louis, MO 63105
Fax: 1-844-273-2671

Expedited appeal requests can be made by phone at 1-855-766-1452 (TTY: 711).

If you or your prescriber believe that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 7 days could seriously harm your health, we will automatically give you a decision within 72 hours. If you do not obtain your prescriber’s support for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

More Information

For more information about coverage determinations and redeterminations refer to your Evidence of Coverage (EOC).

If you have any questions contact Member Services.