Coverage Determinations and Exceptions

What is a coverage determination?

A coverage determination is a decision Buckeye makes about whether a drug prescribed for you is covered by the plan or the amount, if any, you are required to pay for the drug. Coverage determinations are also called coverage decisions.

What is an exception?

If a drug is not covered in the way you would like it to be covered, you can ask us to make an “exception.” An exception is a type of coverage determination. Similar to other types of coverage determinations, if we turn down your request for an exception, you can appeal our decision. When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request.

Asking for a coverage determination or exception

You, your physician, or your appointed representative may file a coverage determination, including an exception, by:

  • Phone: 1-866-399-0928
  • Fax: 1-877-941-0480

You may use the following form to submit your request.

Drug Coverage Determination Form
Determinación de cobertura de medicamentos

If we denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Prescription Drug Coverage to ask us for a redetermination.

You may use the following to submit your redetermination request

Request for Redetermination Form
Solicitud de redeterminación de denegación de cobertura para medicamentos con receta

You can mail or fax us your request. You can also submit your request through our secure member portal online.  To do this, login to our secure portal, attach and submit your request online. If you have not registered for the site, please do so by creating an account.  Registration is fast and simple, give it a try!

If you have any questions about requests for services, please contact your Care Manager or Member Services at 1-866-549-8289. Hours are from 8 a.m. to 8 p.m., Monday through Friday. On weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711.

 

Last Updated: 09/30/2017
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