How to request exceptions to what your Medicare plan covers

This section is a summary of the more complete information in your Priority Health Medicare plan's "Evidence of Coverage" booklet (the links at the bottom of this page let you view this document online).

The process for asking for an exception to what is covered under your plan is different from what you should do if you're unhappy with our service or the service you receive from our network. To make a service complaint, go to the section on service complaints (grievances).

Examples of exceptions

If your doctor or pharmacist tells you that a certain drug or service is not covered and you believe it should be, you or your authorized representative can ask us to:

• Cover a drug that is not on our approved drug list. Generally, we'll only approve your request if the drugs on the approved drug list wouldn't be as effective in treating your condition, and/or if they would cause you more health problems.
• Give you an exception if the drug your doctor wants you to take first requires step therapy (trying other things first) or quantity limits.
• Give you an exception if the service your doctor wants you to have is not covered by your Priority Health Medicare plan.

First, call Customer Service.

We may be able to save you a lot of paperwork if you call us first. Go to Customer Service hours and phone numbers.

Next, request an "initial decision."

1. You don't have to give us your request in writing, but you should ask your doctor to write a statement supporting your request.
   • To request an exception to coverage for services, your doctor should use a Coverage Determination Request Form (237KB PDF).
   • To request an exception to coverage for prescription drugs, your doctor should use the federal government's Request for Medicare Prescription Drug Determination Form (237KB PDF).
2. Customer Service will explain how to submit the statement from your doctor and your request to us by fax or by mail.
3. Unless there are medical reasons for us to respond more quickly, we'll generally make a decision:
   • Within 72 hours of your request for an exception to the drugs we cover
   • Within 2 weeks of your request for an exception to the medical services covered by your plan
4. If you are granted an exception, it will usually be good for the rest of the calendar year.

Filing an appeal

If you aren't satisfied with the initial decision, you can ask us to reconsider. A request for us to reconsider a decision is called "filing an appeal."

• Go to instructions for filing an appeal.
• Learn how to name an authorized representative to act for you.

What is covered by your plan?

For complete information about what's covered under your Priority Health Medicare plan, refer to your plan's "Evidence of Coverage" booklet. Use the links below to open your plan's booklet.

• Go to Chapter 9 of the Evidence of Coverage for PriorityMedicare Value plan, (1.7MB PDF) 
• Go to Chapter 9 of the Evidence of Coverage for PriorityMedicare plan, (1.7MB PDF)  
• Go to Chapter 9 of the Evidence of Coverage for PriorityMedicare Plus plan, (1.7MB PDF) 
• Go to Chapter 9 of the Evidence of Coverage for PriorityMedicare Choice plan, (1.7MB PDF)
  
• Go to Chapter 7 of the Evidence of Coverage for PriorityMedicare Rx plan, (980KB PDF) 

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