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Part D Coverage Determinations

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.

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 non-preferred drug (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. (Note: Our plan cannot cover a drug purchased outside the United States and its territories. Please see Chapter 5 Section 7.1 of the Evidence of Coverage (EOC)).

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).

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 time frames 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.

How Do I Request a Coverage Determination?

You, your doctor, or your appointed representative can request a coverage determination or exception by one of the following three ways:

  1. Click on the following link to start the Part D coverage determination process online:
    Online Coverage Determination (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage website.)
  2. Print and complete the Request for Coverage Determination Form 
    Mail or fax the completed form to:
    EnvisionRx Options
    Attn: Coverage Determinations (Clinical Services)
    2181 E. Aurora Rd, Suite 201
    Twinsburg, OH 44087
    Fax: (877) 503-7231
  3. Call us at (844) 860-6750 (TTY 711)

Part D Coverage Determinations

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.

To submit a paper claim, download and print the Direct Member Reimbursement Form or call Pharmacy Member Services at (844) 860-6750 (TTY 711) to request a paper claim form. You don’t have to use the form, but it will help us process the information faster. You must submit your request with 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:

EnvisionRx Options
Attn: Member Reimbursement Department
2181 E. Aurora Road, Suite 201
Twinsburg, OH 44087

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.

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 (AOR) form on medicare.gov (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage website) and mail it to:

Memorial Hermann Advantage Enrollment
929 Gessner Road
Suite 1500
Houston, TX 77024

Download the Medical Power of Attorney Form.

Additional Resources

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.)