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Coverage Determinations
What are Coverage Determinations?
Coverage determinations are the first decisions made by the plan that determine whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exception requests.
- “Standard” Coverage Determination: For a “standard” coverage determination, the decision will typically be made within a 72-hour timeframe.
- “Fast” or “Expedited” Coverage Determination: You can ask for a “fast”coverage determination ONLY if you or your doctor determine that waiting for a standard decision could seriously harm your health or your ability to function. “Fast” decisions only apply for Part D drugs that you have not yet received. A “fast” coverage determination is made typically within 24 hours.
How Do I Request A Coverage Determination Exception?
To check status or to request a “Standard”, “Fast” or “Expedited” Appeal or Grievance: You, your appointed representative or your prescribing physician should contact us by telephone, fax, mail or hand deliver at the numbers or address below:
Phone: 503-574-8000 or 1-800-603-2340
Fax: 503-574-8646 or 1-800-249-7714
Mail To:
Providence Medicare Plans
Attn: Appeals and Grievance Department
P.O. Box 4327
Portland, OR 97208-4327
Hand Deliver To:
Providence Medicare Plans
Attn: Appeals and Grievance Dept.
3601 SW Murray Blvd., Suite 10
Beaverton, OR 97005
If you have Medicare prescription drug coverage (Part D) with Providence, please refer to your Member Handbook/Evidence of Coverage Section 12, “Getting information to support your appeal”.
Drug Coverage Determination Form (PDF 40kb) You may take this form to your doctor to be completed and faxed to the number above to help facilitate the Coverage Determination Exception process.
For more information about your Coverage Determination Exceptions and Appeals rights, call us or see your Member Handbook/Evidence of Coverage.
Other Resources to Help You
Medicare Rights Center
Toll Free: 1-888-HMO-9050
Elder Care Locater
Toll Free: 1-800-677-1116
1-800-Medicare
(1-800-633-4227)
TTY: 1-877-486-2048
Providence Health Plan is a health plan with a Medicare Advantage contract.
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