Sometimes, you may have difficulty getting the drugs you need. That’s why you have the right to request a coverage determination and get a written explanation from your Medicare drug plan if:
- Your prescriber or pharmacist tells you that your Medicare drug plan will not cover a prescription drug in the amount or form prescribed.
- You are asked to pay a different cost-sharing amount than you think you are required to pay for a prescription drug.
You also have the right to ask your Medicare drug plan for an exception – a special type of coverage determination – and get a written explanation from your Medicare drug plan if:
- You believe you need a drug that is not on your drug plan’s list of covered drugs.
- You believe a coverage rule (such as prior authorization or a quantity limit) should not apply to you for medical reasons.
- You believe you should get a drug you need at a lower cost-sharing amount.
For more information about our complaint and appeals process, visit our Complaints and Appeals page.
For more information on coverage determinations, refer to chapter 6 of the Evidence of Coverage (EOC) for your Prescription Drug plan.
Want to request an exception?
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believes 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 a supporting statement from your doctor or other prescriber.
To request an exception, please call our Member Services Department or send us a Drug Coverage Determination / Exception Form.
Disagree with a prescription drug decision we have made?
You can appeal that decision by completing and sending our Drug Coverage Redetermination Form.
Both forms can be sent by:
511 Farber Lakes Drive
Buffalo, New York 14221
Fax: (716) 635-3504
Note: Either attach a completed form to the e-mail or you may provide the Determination or Redetermination details in the e-mail body.
Pharmacy Benefit Dimensions is a subsidiary of Independent Health. Independent Health is a PDP with a Medicare contract. Enrollment in Pharmacy Benefit Dimensions PDP depends on contract renewal between Independent Health and CMS.