Coverage Determination

Request for Coverage Determination and Appeal

Whenever you ask for a Part D prescription drug benefit, the first step is called requesting a coverage determination. When we make a coverage determination, we are making a determination whether or not to provide or pay for a Part D drug. Coverage determinations include exceptions requests. You have the right to ask us for an “exception” if you believe you need a drug that is not on our 2020 List of Covered Drugs (Formulary) or believe you should get a drug at a lower co-payment. If you request an exception, your physician must provide a statement to support your request. You can request a coverage determination, for example, if:

  • You want us to make an exception to cover a drug not on the List of Covered Drugs (Formulary).
  • You want us to pay for a medication that you already bought.
  • You want us to waive a restriction on our coverage for a drug.

The decision that we make regarding your request is called a coverage determination. If your request is denied, you can then ask us to change our decision, and request a Level 1 Appeal. You cannot request an appeal if we have not issued a coverage determination.

How to Request a Coverage Determination

You, or your appointed representative, or the prescriber may request a coverage determination by calling RiverSpring MAP (HMO D-SNP) Pharmacy Services, at 1-855-898-1482 (TTY/TDD: 711), 24 hours a day, 7 days a week, or by fax to 1-855-898-1483.

When you request an exception, your physician or other prescriber must provide a statement to explain the medical reasons to support your request. This supporting statement from your physician or prescriber must be sent to MeridianRx, our pharmacy benefit manager, at:

MeridianRx
1 Campus Martius, Suite 750
Detroit, MI 48226

Or you may fax it to 1-855-898-1483.

You can also submit a Part D Coverage Determination Request form online by visiting our Pharmacy Benefit Manager’s website

A standard coverage determination will be made within 72 hours. If you or your physician believe that waiting for a standard decision could seriously harm your health or your ability to function, you can ask for an expedited or fast determination, which will be made within 24 hours.

To view appeals, grievance and coverage determination processes, please review Chapter 9 of the Evidence of Coverage.

How to File an Appeal

You have the right to appeal if we issued a decision to deny your request for coverage or payment.

If you want to appeal, you must request your appeal within 60 calendar days from the date of our written notice of coverage or payment decision. If you have a good reason for missing the appeal deadline and need more time, please contact us.

You, or your appointed representative, or the prescriber may request an expedited appeal or standard appeal by calling RiverSpring MAP (HMO D-SNP) Pharmacy Services at 1-855-898-1482, 24 hours a day, 7 days a week, or fax a request to 1-855-898-1483. You may also send your request for an appeal to:

MeridianRx
1 Campus Martius, Suite 750
Detroit, MI 48226

For more information regarding coverage determinations and appeals, see the  Evidence of Coverage.

The Request for Medicare Prescription Drug Coverage Determination Form is available from CMS using the following link

In your written request, please include your name, address, member ID number, the reason(s) for appealing, and any evidence you wish to attach. If your appeal relates to a decision by us to deny a drug that is not on our List of Covered Drugs (Formulary), your prescriber must indicate that the drugs on our List of Covered Drugs (Formulary) would not be as effective to treat your condition as the requested off-formulary drug or would harm your health. We will then review your case and make a decision.

Upon denial, you may ask for a review by a government-contracted independent review entity (IRE). If you disagree with the IRE decision, you will have the right to further appeal. You will be notified of your appeal rights if this happens.

Last updated on October 7, 2019