CenterLight Healthcare Direct

Medicare Part D Information for Members

Coverage Determinations/Exception Requests

For situations in which you have a medication that is not on CenterLight Healthcare Direct’s formulary or is part of a tier level designated as non-preferred, but you believe it should be placed in a different tier, an exceptions process has been established by the plan. Exception requests will be reviewed by the Plan for coverage determination.

Your prescribing physician must provide supporting medical information in response to a coverage exception request related to a non-formulary drug or tier placement.

There are two kinds of coverage determination requests – fast and standard.

A member can request a fast coverage determination, which will be decided within 24 hours. The request for a fast coverage determination must meet criteria that the standard coverage determination review process time frame would jeopardize the member’s health status.

For standard coverage determination requests, notification will occur 72 hours after receipt of the request or written documentation of medical necessity from the physician.

Non-formulary drugs approved for coverage will be covered at the non-preferred brand level. Biotech and specialty non-formulary products approved for coverage will be covered at the specialty level. A fast coverage determination or exception request can be made verbally by calling 1-800-935-7195 (TTY/TDD users call: 1-800-855-2881) Monday - Sunday, 8:00 a.m. – 8:00 p.m. To make a coverage determination request or an exception request, see instructions and forms below

  Coverage Determination Form (for submission by Members) (PDF, 27KB)

  Coverage Determination Request Form (for submission by Providers) (PDF, 106KB)

Information on the aggregate number of CenterLight Healthcare Direct’s grievances, appeals and exceptions is available by contacting CenterLight Healthcare Direct Member Services at 1-877-266-8500 (TTY users call: 711) Monday - Sunday, 8:00 a.m. – 8:00 p.m.

Please review the Evidence of Coverage for your specific plan for more detailed information on coverage determination, exception requests and appeals requests.

Appeals (Redetermination and Reconsideration)

A member appeal can be submitted when you want us to reconsider and change a decision we have made about what prescription drug benefits are covered for you or what we will pay for a prescription drug. An appeal must be filed within 60 calendar days of the coverage determination. Two types of appeals are available to members – a fast-track appeal and a standard appeal.

Members who submit a fast-track appeal must meet criteria that the standard process time frame would jeopardize the member's health status. These fast reviews will be completed within 72 hours.

Standard appeal requests will be reviewed within 7 calendar days.

Members can make a fast-track appeal request by calling 1-877-226-8500 (TTY users should call 711). To make a standard appeal request, see instructions and attached forms below.

  Member IRE Reconsideration Form (Last Updated: January 1, 2009) (PDF, 22.6KB)

  Provider Prescription Redetermination (Appeal) Form (Last Updated: October 1, 2008) (PDF, 54.6KB)

How to Appoint a Representative

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 another person to be your representative, call Member Services and ask for the form that will give that person permission to act on your behalf. You can also get the form from the link below. 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.

  Appointment of Representative Form (PDF, 37.4KB)

  Appointment of Representative Form (Spanish) (PDF, 39.1KB)

  Member IRE Reconsideration Form (Last Updated: January 1, 2009) (PDF, 22.6KB)

Grievances

A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with CenterLight Healthcare Direct or one of our network pharmacies that does not relate to coverage for a prescription drug. If you have a grievance, we encourage you to call Member Services for a prompt response. We will try to resolve any complaint over the phone. You may also send your complaint in writing. To submit a grievance in writing, please mail to:

Medco Health Solutions, Inc.
PO Box 14711
Lexington, KY 40512

You can also fax a grievance to: 1-972-915-6104. We will notify you of a decision within 30 days of receipt of the written grievance. We may extend this time frame by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. An expedited grievance can be made orally by calling 1-800-935-7195 (TTY/TDD users call: 1-800-855-2881) Monday - Sunday, 8:00 a.m. to 8 p.m.

Prior Authorization Criteria

You will need authorization before filling prescriptions for the drugs shown in the   2012 Prior Authorization Criteria (PDF, 83.9KB). We will only provide coverage after it is determined that the drug is being prescribed according to the criteria specified in the chart. You, your pharmacist or your physician can request prior authorization by calling Medco toll-free at 1-800-753-2851, 8:00 a.m. to 9:00 p.m. Eastern Time, Monday through Friday. Customer Service is available in English and other languages. TTY/TDD users should call 1-800-716-3231.

Transition Policy

New members in our plan may be taking drugs that aren't on our Formulary, or that are subject to certain restrictions, such as prior authorization or step therapy. Current members may also be affected by changes in our Formulary from one year to the next. Members should talk to their doctors to decide if they should switch to a different drug that we cover or request a Formulary exception in order to get coverage for the drug. See Section 5 of your Evidence of Coverage under "What is an exception?" to learn more about how to request an exception. Please contact Member Services if your drug is not on our Formulary, is subject to certain restrictions, such as prior authorization or step therapy, or will no longer be on our Formulary next year, and you need help switching to a different drug that we cover or requesting a Formulary exception.

During the period of time members are talking to their doctors to determine the right course of action, we may provide a temporary supply of the non-Formulary drug if those members need a refill for the drug during the first 90 days of new membership in our Plan. If you are a current member affected by a Formulary change from one year to the next, we provide you with the opportunity to request a Formulary exception in advance for the following year.

When a member goes to a network pharmacy and we provide a temporary supply of a drug that isn't on our Formulary, or that has coverage restrictions or limits (but is otherwise considered a "Part D drug"), we will cover a 31-day supply (unless the prescription is written for fewer days). After we cover the temporary 31-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.

If a new member is a resident of a long-term care facility (such as a nursing home), we will cover a temporary 31-day transition supply (unless the prescription is written for fewer days). If necessary, we will cover more than one refill of these drugs during the 90 days a new member is enrolled in our Plan. If the resident has been enrolled in our Plan for more than 90 days and needs a drug that isn't on our Formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a Formulary exception.

Please note that our transition policy applies only to those drugs that are "Part D drugs" and bought at a network pharmacy. The transition policy can't be used to buy a non-Part D drug or a drug out of network, unless you qualify for out of network access. See Section 10 of your Evidence of Coverage for information about non-Part D drugs.

You may also view the Spanish language version of this document by clicking on the following link:

  Política de Transición (PDF, 16.9KB)

Best Available Evidence of Low-Income Subsidy Status

If you believe that you are paying too much for your prescription drugs because CenterLight Healthcare does not have the correct low-income subsidy status, please call our Member Services Department. We can help you find out if you should be paying less for your prescription drugs because you are eligible for Medicaid and/or the low-income subsidy. Please visit the Centers for Medicare and Medicaid Services website to learn more.