What Is a Coverage Determination?
A coverage determination is a decision we make about your benefits and coverage or about the amount we will pay for your Part D prescription drugs. As a member of Memorial Hermann Advantage, you have the right to request a coverage determination with regard to the prescription drug coverage you are entitled to receive under your plan, including:
- Asking us to cover a Part D drug that is not on the plan’s formulary.
- Asking us to waive a restriction on the plan’s coverage for a drug (such as prior authorization, step therapy or quantity limit restrictions).
- Asking to pay a lower cost-share for a medication listed in one of the non-preferred tiers (i.e. Tier 2 or Tier 4). This does not apply toward coverage of drugs in the Specialty Tier 5 category.
- Asking us to cover reimbursement for prescription drugs that you have already purchased.
How Long is the Coverage Determination Process?
Memorial Hermann Advantage has both a standard and a fast (sometimes called “expedited”) procedure in place for making coverage determinations. When requesting a coverage determination, you, your doctor or appointed representative should let us know which of the two decision timeframes you need.
Standard Decision. A decision about whether we will cover a Medicare prescription drug (Medicare Part D) that is made within the standard time frame (typically within 72 hours).
Fast Decision. A decision about whether we will cover a Medicare prescription drug (Medicare Part D) that is made more quickly (typically within 24 hours). A fast decision is sometimes called an "expedited coverage determination."
You can ask for a fast decision only if you or your doctor believe that waiting for a standard decision could seriously harm your health or your ability to function. Fast decisions apply only to requests for Medicare prescription drugs (Medicare Part D) that you have not received yet. You cannot get a fast decision if you are requesting payment for a Medicare prescription drug (Medicare Part D) that you already received.
What drugs require a coverage determination?
Some drugs may require a coverage determination if they have a prior authorization. Here is a list of drugs that require a prior authorization:
List of Drugs that Require Prior Authorization (Pending CMS approval)
How Do I Request a Coverage Determination?
You, your doctor or your appointed representative can request a coverage determination (standard or fast) by one of the following three ways:
- Click on the following link to start the Memorial Hermann Advantage coverage determination process online:
Online Coverage Determination (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage website.)
Use the following links to download our list of drugs that require prior authorization. Print and complete the form you need to request prior authorization, coverage determination or exception.
Request for Coverage Determination Form
- Mail or fax your coverage determination request to:
Envision Rx Options
Attn: Coverage Determinations (Clinical Services)
2181 E. Aurora Rd, Suite 201
Twinsburg, OH 44087
Fax: (877) 503-7231
- Call us.
Memorial Hermann Advantage HMO members should call (844) 860-6750.
Memorial Hermann Advantage PPO members should call (844) 782-7672. TTY/TDD users can call 711.
Direct Member Reimbursement
There may be situations in which you may ask us to pay for a prescription drug you already purchased. The following are examples of when you may submit a paper claim:
- If there are no participating pharmacies near you, we will cover prescriptions filled at an out-of-network pharmacy in the event of an emergency as defined by the plan.
- When you pay the full cost for a prescription because you do not have your Memorial Hermann Advantage membership card with you.
- When you pay the full cost for a prescription drug that is not on the plan's Drug List or if the drug has additional restrictions that you do not think should apply to you.
Filling Prescriptions Outside the Network
Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. To ensure that Memorial Hermann Advantage will allow an out-of-network pharmacy before you fill your prescription, call Member Services to see if there is a network pharmacy in your area where you can fill your prescription.
If you go to an out-of-network pharmacy due to a health emergency, you may have to pay the full cost (rather than paying just your co-pay) when you fill your prescription. In the event of using an out-of-network pharmacy for an emergency, you can ask us to reimburse you for our share of the cost by submitting a paper claim form called a Direct Member Reimbursement (DMR).
However, even after we reimburse you for our share of the cost, you may pay more for a drug purchased at an out-of-network pharmacy because the out-of-network pharmacy’s price may be higher than a network pharmacy’s. Regardless of the amount, we can only reimburse you the amount that we would have paid if you had the prescription filled at a network pharmacy. Even though you may not receive the full amount you paid in reimbursement, the amount that you paid may still be counted toward your required out-of-pocket costs in reaching the catastrophic stage.
To submit a paper claim when an out-of-network pharmacy is used in the case of an emergency, download and print the DMR form or call Pharmacy Member Services at (844) 860-6750 (HMO) or (844) 782-7672 (PPO). TTY/TDD users may call 711 to request a paper claim form. This form must be completed and returned along with your original paper receipt from the pharmacy within the first 90 days of receiving your prescription. If you do not have a copy of your pharmacy receipt you can ask your pharmacy to reprint a copy for you. Mail the reimbursement form and receipts within 90 days to the address below:
Attn: Member Reimbursement Department
2181 E. Aurora Road, Suite 201
Twinsburg, OH 44087
Direct Member Reimbursement
For more information on asking for coverage decisions about your Part D prescription drugs, please refer to Chapter 9 in your Evidence of Coverage (EOC).
What is an appeal?
An appeal is a special kind of complaint you make if you disagree with a decision to deny a request for health care services and/or prescription drugs or payment for services and/or prescription drugs you already received. You may also make a complaint if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if our plan doesn’t pay for a drug/item/service you think you should be able to receive.
How long is the appeal process?
Memorial Hermann Advantage has both standard and fast (sometimes called expedited) appeal procedures. When requesting an appeal, you, your doctor, or appointed representative should let us know which of the two decision timeframes you need.
Standard Appeal When we review a standard appeal, 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. If you believe your health requires it, you should ask for a “fast” appeal.
Fast Appeal When we review a fast appeal, we must give you our answer within 72 hours 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.
You can ask for a fast appeal only if you or your doctor believe that waiting for a standard appeal could seriously harm your health or your ability to function. Fast appeals apply only to requests for Medicare prescription drugs (Medicare Part D) that you have not received yet. You cannot get a fast appeal if you are requesting payment for a Medicare prescription drug (Medicare Part D) that you already received.
How do I request an appeal?
You, your doctor or your appointed representative must request an appeal (request for redetermination) within 60 days from the date of the notice of the adverse coverage determination (date printed or written on the notice). There are three ways you may request your standard or fast appeal. For more detailed information refer to Chapter 9 of your Evidence of Coverage.
- Click on the following link to start the Memorial Hermann Advantage redetermination process online: Online Redetermination.
- Download form and complete to mail or fax to us.
Redetermination Request Form
Memorial Hermann Advantage
Attn: Appeals and Grievance Department
7737 Southwest Freeway Suite C-97
Houston, Texas 77074
- Call us at 1-844-550-6886 (HMO) or 1-844-550-6896 (PPO). TTY/TDD users should call 711.
What happens after I request a standard appeal?
Memorial Hermann Advantage will review the standard appeal (request for redetermination) and will provide you notice of our decision in writing (and process the change if favorable) as expeditiously as your health condition requires but no later than 7 calendar days of receipt of the appeal request. If Memorial Hermann Advantage decides that the time frame for the standard appeals process could seriously jeopardize your life, health or ability to regain maximum function, the review of your request will be expedited.
What happens after I request a fast (expedited) appeal?
If Memorial Hermann Advantage decides that the time frame for the standard appeals process could seriously jeopardize your life, health or ability to regain maximum function, the review of your request will be expedited. A request made or supported by your prescribing physician will be expedited if the physician indicates that applying the standard timeframe for making a determination may seriously jeopardize your life or health or your ability to regain maximum function. When an appeal request meets criteria for expedited processing, Memorial Hermann Advantage must provide you and your prescribing physician notice of its decision (and effectuate the change if favorable) as expeditiously as your health condition requires, but no later than 72 hours after receiving the request.
If additional medical information is required to process the request, Memorial Hermann Advantage must request it within 24 hours of receiving the fast appeal request. Even if additional information is required, Memorial Hermann Advantage must still issue notice of the decision within the 72-hour timeframe.
If Memorial Hermann Advantage determines that your request is not time-sensitive, where your health is not seriously jeopardized, Memorial Hermann Advantage will notify you verbally and in writing and will automatically begin processing your request under the standard appeals process. If you disagree and believe the review should be expedited, you may file an expedited grievance with Memorial Hermann Advantage. The written notice will include instructions on how to file an expedited grievance. You have the right to resubmit your request for an expedited appeal with your prescribing physicians support.
Your prescriber may ask us for an appeal on your behalf. 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 can appoint a representative to act on your behalf by providing us a completed Appointment of Representative Form.
Further Appeal Rights
If you disagree with a decision Memorial Hermann Advantage made regarding your appeal (request for redetermination), you may file an appeal with an outside entity. For further information regarding appeals, refer to Chapter 9 of your Evidence of Coverage or call Member Services 8 a.m. to 8 p.m., 7 days a week at 1-844-550-6886 (HMO) or 1-844-550-6896 (PPO). TTY/TDD users should call 711.
Appointment of Representative Form
If you need someone to file a grievance, coverage determination or appeal on your behalf, you can name a relative, friend, advocate, doctor or anyone else as your appointed representative. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative.
If you want to appoint a representative, download Medicare's Appointment of Representative Form. You may also complete the Appointment of Representative form on medicare.gov (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage website) website and mail it to:
Memorial Hermann Advantage Enrollment
929 Gessner Road
Houston, TX 77024
Download the Medical Power of Attorney Form.
CMS' Best Available Evidence policy (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage website).
You may also file a complaint directly to Medicare by calling 1-800-Medicare or by visiting medicare.gov. (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage website.)