Coverage Determinations

What is a coverage determination?

There are two different types of coverage determinations:

1. Prior Authorization
Certain prescription drugs on our formulary need a statement/form from your doctor explaining why this drug is medically necessary to treat your condition. This statement/form is called a prior authorization. We need prior authorizations to make sure that these drugs are used correctly and only when medically necessary.

2. Formulary Exception
There are several types of exceptions that you can ask us to make.

If you are a UCare for Seniors member, there are two types of requests you can make for an exception to our coverage rules:

1. You can ask us to waive coverage restrictions or quantity limits on your drug.
2. You can ask us to change the tier of your drug (i.e., from brand name to preferred brand).

If you are a UCare’s Minnesota Senior Health Options (MSHO) member, there are two types of requests you can make for an exception to our coverage rules:

1. You can ask us to cover your drug even if it is not on our formulary.
2. You can ask us to waive coverage restrictions or quantity limits on your drug.

Generally, UCare will only approve your request for an exception if the alternative drugs included on the plan’s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

How do I work with my physician to request a coverage determination?

You can ask us for a coverage determination yourself, or your prescribing physician or someone you name as your appointed representative may do it for you. When you ask for a coverage determination, you should submit a statement from your physician supporting your request. UCare encourages you and your physician to work together to request a coverage determination using the Request for Medicare Prescription Drug Coverage Determination Form. This form includes a section for you to fill out and a section for your physician to complete. Alternatively, your physician can use the Physician Prior Authorization and Exception Forms.

Generally, we must make our decision within 72 hours of getting your prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician’s supporting statement.

How do I get reimbursed if I pay out of pocket for a Part D drug?

If you submit a paper claim for a Part D drug you purchased out of pocket, UCare will make a coverage determination to decide if the drug is eligible for reimbursement.

How do I appoint a representative?

You can name a relative, friend, advocate, doctor, an attorney, or anyone else to act for you. Some other persons may already be authorized under State law to act for you. If you want someone to act for you, then you and that person must sign and date a statement or fill out the Medicare Appointment of Representative form (Form CMS-1696) (PDF). This statement or form gives the person legal permission to act as your appointed representative. Send the statement or Medicare Appointment of Representative form to UCare, Attn: Customer Services, P.O. Box 52, Minneapolis, MN 55440-0052.

Who may file your appeal of the coverage determination?

For a standard request, you or your appointed representative may file the request. A fast appeal may be filed by you, your appointed representative, or your prescribing physician. Send the form or statement with your request for appeal to UCare Member Complaints, Appeals, and Grievances, UCare, P.O. Box 52, Minneapolis, MN 55440-0052. Or call 612-676-6841 or 1-877-523-1517 (toll free). Or fax your written Coverage Determination to 612-884-2021 or 1-866-283-8015 (toll free).

Coverage Determinations

What is a coverage determination?

There are two different types of coverage determinations:

1. Prior Authorization
Certain prescription drugs on our formulary need a statement/form from your doctor explaining why this drug is medically necessary to treat your condition. This statement/form is called a prior authorization. We need prior authorizations to make sure that these drugs are used correctly and only when medically necessary.

2. Formulary Exception
There are several types of exceptions that you can ask us to make.

If you are a UCare for Seniors member, there are two types of requests you can make for an exception to our coverage rules:

1. You can ask us to waive coverage restrictions or quantity limits on your drug.
2. You can ask us to change the tier of your drug (i.e., from brand name to preferred brand).

Generally, UCare will only approve your request for an exception if the alternative drugs included on the plan’s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

How do I work with my physician to request a coverage determination?

You can ask us for a coverage determination yourself, or your prescribing physician or someone you name as your appointed representative may do it for you. When you ask for a coverage determination, you should submit a statement from your physician supporting your request. UCare encourages you and your physician to work together to request a coverage determination using the Request for Medicare Prescription Drug Coverage Determination Form (Coming soon). This form includes a section for you to fill out and a section for your physician to complete. Alternatively, your physician can use the Physician Prior Authorization and Exception Forms.

Generally, we must make our decision within 72 hours of getting your prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician’s supporting statement.

How do I appoint a representative?

You can name a relative, friend, advocate, doctor, an attorney, or anyone else to act for you. Some other persons may already be authorized under State law to act for you. If you want someone to act for you, then you and that person must sign and date a statement or fill out the Medicare Appointment of Representative form (Form CMS-1696). This statement or form gives the person legal permission to act as your appointed representative. Send the statement or Medicare Appointment of Representative form to UCare, Attn: Customer Services, P.O. Box 52, Minneapolis, MN 55440-0052.

Who may file your appeal of the coverage determination?

For a standard request, you or your appointed representative may file the request. A fast appeal may be filed by you, your appointed representative, or your prescribing physician. Send the form or statement with your request for appeal to UCare Member Complaints, Appeals, and Grievances, UCare, P.O. Box 52, Minneapolis, MN 55440-0052. Or call 612-676-6841 or 1-877-523-1517 (toll free).