If a drug is not covered in the way you would like it to be covered, you can ask us to make an exception or coverage decision to our coverage rules. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision. When you ask for an exception, please explain the medical reasons why you need the exception approved for consideration. More information can be found on the Medicare Part D (Pharmacy) Information page or the Evidence of Coverage (PDF).
You can use one of the following methods to request a formulary exception:
Making an Appeal/Redeterminations
If we make a coverage decision and you are not satisfied with this decision, you can appeal the decision or ask for a redetermination. You must make your appeal request within 60 calendar days from the date on the coverage decision written notice we sent. More information can be found on the Medicare Part D (Pharmacy) Information page or the Evidence of Coverage (PDF).
You can use one of the following methods to request an appeal:
Please contact our Member Services number at 1-844-269-3442 for additional information. (TTY users should call 711.) From October 1 to March 31, we are open 7 days a week, from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we are open Monday through Friday, from 8 a.m. to 8 p.m. EST.
We do not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, gender identity, age or disability in our health programs and activities.
ATENCION: Si habla español, tiene a su diposicion servicios gratuitos de assistencia linguistica. Llame a 1.844.269.3442 / TTY: 711
Health Pointe Direct Complete Plan (HMO SNP) is a Health Plan with a Medicare Contract. Enrollment in Health Pointe HMO SNP depends on contract renewal.
CMS Material ID: H1722_HPweb2019 | Last updated 10/01/2019