Coverage Determinations and Redeterminations | Allwell from Silver Summit Health

Coverage Determinations and Redeterminations for Drugs


A coverage determination is a decision about whether a drug prescribed for you will be covered by us and the amount you’ll need to pay. If a drug is not covered or there are restrictions or limits on a drug, you may request a coverage determination.

You can ask us to cover:

  • a drug that is not on our list of drugs.
  • a drug that requires prior approval.
  • a drug at a lower cost sharing tier, as long as the drug is not on the specialty tier (Tier 5).
  • a higher quantity or dose of a drug.

You, your representative, or your doctor may submit a coverage determination request by fax, mail or phone. You must include your doctor’s statement explaining why your drug is necessary for your condition. Within 72 hours after we receive your doctor’s statement, we must make our decision and respond. If we deny your request you can appeal our decision. Information on how to file an appeal will be included in the denial notice.

Generally, we will only approve your request for an exception if the alternative drug is included on our formulary, the lower cost-sharing drug or additional restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You also can contact Member Services.


Drug Coverage Determination Form By mail:  By fax: By phone:

Drug Coverage Determination Form (HMO) - English (PDF)

Drug Coverage Determination Form (HMO) - Spanish (PDF)

Medicare Pharmacy Prior Authorization Department
P.O. Box 31397
Tampa, FL  33631-3397
1-866-226-1093 1-833-854-4766 
(TTY: 711)

For Doctors and Other Prescribers ONLY call: 1-800-867-6564  (TTY: 711)

Prescription Reimbursement

If you need to ask for reimbursement for prescriptions paid out-of-pocket:

  1. Complete the Prescription Claim Form - English (PDF) | Prescription Claim Form -  Spanish (PDF)
  2. Attach the original prescription receipt to the form. If you do not have the original receipt, you can ask your pharmacy for a printout. Do not use cash register receipts.
  3. Mail the completed form and receipt to the address on the form.

After we receive your request, we will mail our decision (determination) with a reimbursement check (if applicable) within 14 days. For specific information about drug coverage, refer to your Evidence of Coverage (EOC) or contact Member Services.

Standard and Fast Decisions

If you or your doctor believe that waiting 72 hours for a standard decision could seriously harm your health, you can ask for a fast (expedited) decision. This applies only to requests for Part D drugs that you have not already received. We must make expedited decisions within 24 hours after we get your doctor’s supporting statement.

If we approve your drug’s exception, the approval continues until the end of the plan year. To keep the exception in place for the plan year, you must remain enrolled in our plan, your doctor must continue to prescribe your drug, and your drug must be safe for treating your condition.

After we make a decision, we send you a notice explaining our decision. The notice includes information on how to appeal a denied request.


If we deny your request for coverage of (or payment for) a drug, you, your doctor, or your representative may ask us for a redetermination (appeal). You have 60 days from the date of our denial notice to request a redetermination. You can complete the Redetermination form, but you are not required to use it. You can send the form, or other written request, by mail or fax to:

Attn: Medicare Pharmacy Appeals
P.O. Box 31383
Tampa, FL 33631-3383
Fax: 1-866-388-1766

Expedited appeal requests can be made by phone at HMO: 1-833-854-4766; (TTY: 711) and HMO SNP: 1-833-717-0806; (TTY: 711).

If you or your doctor states that waiting 7 days for a standard decision could seriously harm your health or ability to regain maximum function, you can ask for a fast (expedited) decision. If your doctor states this, we will automatically give you a decision within 72 hours. If we do not receive your doctor’s supporting statement for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

Drug Coverage Redetermination Form By mail:  By fax: By phone:

Request for Redetermination Form (HMO) - English (PDF)

Request for Redetermination Form (HMO) - Spanish (PDF)

Attn: Medicare Pharmacy Appeals
P.O. Box 31383
Tampa, FL 33631-3383
1-866-388-1766 1-833-854-4766 
(TTY: 711)

More Information

For more information about coverage determinations and redeterminations refer to your Evidence of Coverage (EOC)

If you have any questions contact Member Services.