When to Request a Drug Coverage Determination
Certain drugs require a determination before they can be covered. If your medication requires this step, you, your appointed representative or the prescriber will need to request and receive approval for CarePlus to cover it. If a request was denied, you may submit a request for redetermination (submit an appeal).
Why is Drug Coverage Determination Required?
Determination is required for certain high-risk or high-cost medications. We want to make sure these medications do not interfere with others you take or add to your costs unnecessarily.
How to Request Drug Coverage Determination
There are several ways you, your representative or your prescriber can submit your request.
Ask your Prescriber to Submit a Request for You
Your prescriber can call the following number or submit a request online.
Call the CarePlus Pharmacy Utilization Management Unit
We are available Monday - Friday, 8 a.m. to 8 p.m.
If your prescriber calls this number, we can answer any questions and provide a coverage determination form specifically for the requested drug. Then your prescriber can submit the completed form by fax at: 1-800-310-9071
Submit request through CoverMyMeds
Submit the Request through the Online Form
Complete the Coverage Determination Request Form in
This is a general form that is not specific to your drug. The CarePlus Pharmacy Utilization Management Unit may need to contact your prescriber for additional information before we can make a determination for the drug.
If You or Your Representative Submits Your Request
You or your representative may submit your request online, by fax, by mail or
Submit your request online
Complete the Coverage Determination Request Form in (
You will need to submit supporting documents from your prescriber to help us determine if you medically need the requested medication. Your information will be sent to us securely.
Fax or mail the form
Download a copy of the form below and fax or mail it to CarePlus:
You can also access Medicare’s
Fax your form:
1-800-310-9071
Mail your form:
CarePlus Health Plans
Attention: CarePlus Pharmacy Utilization Management Unit
P.O. Box 277810
Miramar, FL 33027
If a representative (other than you or your prescriber) submits the request for you, please provide a legal representation form with your request or make sure you have completed an
We will let you know if the request was approved or denied no later than 72 hours for standard requests or 24 hours for expedited requests, once it has been received. For exceptions, the timeframe begins when we obtain your prescriber’s supporting statement. Your request will be expedited if we determine or if your prescriber tells us that your life, health, or ability to regain maximum function may be seriously jeopardized by waiting for a standard decision.
What if we determine your prescription drug is not covered?
In some cases CarePlus might deny your request for coverage of a prescription drug. If we deny all or part of your request, we will send you a detailed written explanation and instructions on
How to obtain grievance, coverage determinations (including Medicare Part D exceptions) and appeal data.
You can find detailed information in Chapter 9 of the CarePlus Evidence of Coverage (EOC) with regard to grievances, coverage determinations (including exceptions), and the appeals process. You will find links to the EOC on the
To obtain information on the aggregate number of grievances, coverage determinations (including Medicare Part D exceptions), and appeals filed with the plan, please call Member Services at
