Part D Coverage Determinations

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Questions? Contact Customer Service at (855) 645-8448

What Is a Coverage Determination?

A coverage determination is a decision we make 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. If you authorize a representative to act on your behalf, a copy of the signed Appointed Representative form or Power of Attorney must be submitted (see below for more information).

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 two 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:

    Memorial Hermann Health Plan
    C/O Navitus Health Solutions, LLC
    Attn: Prior Authorization
    P.O. Box 1039
    Appleton, WI 54912-1039
    Fax: (855) 668-8552
    Call us at (844) 860-6750 (TTY 711)

Part D Coverage Determinations and Reimbursement Requests

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. We cannot pay for any prescriptions that are filled by pharmacies outside of the United States and its territories, even for a medical emergency. 
  • 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 (866) 270-3877 (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:

Memorial Hermann Health Plan Manual Claims
C/O Navitus Health Solutions, LLC
Member Reimbursement Department
P.O. Box 1039
Appleton, WI 54912-1039

Direct Member Reimbursement Form - English
Direct Member Reimbursement Form - Spanish

What if my request for a Coverage Determination is denied?

If your request for a coverage determination is denied, you will be given a written explanation of our decision. We may deny your request altogether or in part with explanation of the decision. If a coverage decision denies any part of your request, you have the right to appeal the decision (request a Redetermination). To start your appeal, you (or your representative or your prescriber) must contact us. Include any information that may be helpful with your redetermination request. You must ask for your appeal within 60 calendar days after the date of the denial notice. We can give you more time if you have a good reason for missing the deadline. You, your prescriber or your appointed representative may ask for an expedited (fast) or standard appeal. If you have questions regarding the prescription drug Coverage Determination process, please call Pharmacy Member Services at (866) 270-3877 (TTY 711) 24 hours a day, 7 days a week.

Filing a Grievance

A Grievance is a formal complaint about quality of care or other services you get from your plan. You or your appointed legal representative may file a grievance, and it is best to file a grievance as soon as you experience a problem you want to complain about (must be filed within 60 days after you had the problem).

For problems or complaints related to your benefits, your coverage or payment, use the Coverage Determination and Appeals process mentioned above. If you are unsure if your request is a Grievance, Coverage Determination Request or an Appeal, please call Pharmacy Member Services at (855) 645-8448 (TTY 711) and we will try to resolve your complaint or concern over the phone. If there is anything else you need to do, Pharmacy Member Services will inform you. You may also request an Expedited/Fast Grievance Process with Pharmacy Member Services.

You may also fax your grievance to us at (713) 338-5811 or mail us at:

Memorial Hermann Advantage HMO
Appeals & Grievances
929 Gessner Road
Suite 1500
Houston, TX 77024

For more information regarding the Medicare Grievance Process, please refer to the chapter in your Evidence of Coverage entitled, "What to do if you have a problem or complaint."

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

You may also file a complaint directly to Medicare by calling 1-800-MEDICARE or by completing the Medicare complaint form on medicare.gov. (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage website.)

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