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Medication Requests and Information

What is a Coverage Determination?

A coverage Determination is any decision made by a health plan regarding coverage benefits to which a plan enrollee believes he or she is entitled.

If you would like to request a coverage determination or an exception to the rules or restrictions on our plan’s coverage of a drug that you are currently taking or your provider is planning for you to take that drug, you may download the Coverage Determination Request Form below and submit to us via mail or fax. If you need assistance, you can always contact the Pharmacy Technical Help desk TTY should be 888-495-3166 (TTY). They’re available 24 hours a day, 7 days a week.

Click the link below to download the Coverage Determination Request Form.

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To request a coverage determination electronically, click here.