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What If I Have a Problem Getting Coverage?

If you are having a hard time getting coverage, there are steps you can take to ask for it.

Organization determinations for Medicare Part C

This is the first step for requests you may have about:

  • Covering Medicare Part C medical care or service.
  • Paying for Part C medical care or service.

You, your provider, or someone you name may ask us for an organization determination. The person you name would be your appointed representative. To learn how to do this, contact Member Services.

We decide whether to give you, or pay for, the Medicare Part C medical care or service you are asking for. We can make a decision in 14 calendar days. We can also make a fast decision within 72 hours. A fast decision is also called an "expedited decision." If you want to find out more, see your Evidence of Coverage, Chapter 9 (PDF — June 18, 2019). You can also call Member Services for help.

Coverage determinations for Medicare Part D

This is the first step for requests you may have about:

  • Covering a Medicare Part D drug you need.
  • Paying for a Medicare Part D drug you already received.

An "exception" is a type of coverage decision. You can ask us to make an "exception." You would do this if a drug is not covered the way you would like it to be covered.

You, your provider, or someone you name may ask us for a coverage determination. The person you name would be your appointed representative. To learn how to name your appointed representative and get instructions, you may call Member Services. You can also fill out and return the Appointment of Representative (AOR) Form (PDF).

We make a decision to give you, or pay for, the Medicare Part D drug you are asking for. We can make a decision in 72 hours. We can also make a fast decision in 24 hours. A fast decision is also called an "expedited decision."

To learn more about a coverage determination or an exception, go to our prescription drug FAQ page.

You can also look at the Evidence of Coverage, Chapter 9 (PDF — June 18, 2019). Or you can contact Member Services.

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