2023 Part D Coverage Determinations

Care N’ Care wants to offer the best prescription drug benefit by providing excellent service and a thorough list of covered drugs.  However, if you are not completely satisfied, you have the right to submit a coverage determination, appeal or grievance, if needed. This page describes how and why to submit coverage determinations.  For more information on submitting a Part D drug appeal or grievance, please see the Part D Appeals and Grievances page.  For additional information on Part D coverage determinations, appeals and grievances, see your Evidence of Coverage which can be downloaded on the Plan Documents page.

Coverage determinations

A coverage determination is an initial coverage decision made by Care N’ Care regarding your Medicare Part D prescription drug.  Here are examples of coverage decisions you can ask us to make about your Part D drugs:

  • You can ask whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on the Plan’s List of Covered Drugs but requires our approval before it is covered.)
  • You can ask us to pay for a prescription drug you already bought (direct member reimbursement request)
  • You can ask us for an exception. (If a drug is not covered in the way you would like it to be covered, you can ask the Plan to make an “exception.”) Examples include:
    • Asking for coverage of a drug that is not on the drug list (nonformulary exception request)
    • Asking to pay a lower cost-sharing amount for a covered non-preferred drug (tier exception request)
    • Asking us to remove the extra rules and restrictions on the Plan’s coverage for a drug such as:
      • Being required to use the generic version of a drug instead of the brand name drug
      • Getting plan approval in advance before we will agree to cover a drug for you
      • Quantity Limits

Your doctor can provide a statement to support these types of requests.

How to request a coverage determination

As a Care N’ Care member, you, your appointed representative, or your prescribing physician may request a coverage determination. You or your appointed representative (your doctor, attorney, advocate, relative, friend or other person authorized to act on your behalf) can submit an online request, call, fax or mail in a request for a coverage determination as described below. We prefer that you have your prescribing physician submit an online request or fax Elixir with a supporting statement for your request.

Elixir
Attn: Coverage Determinations
2181 E. Aurora Road, Suite 201
Twinsburg, OH 44087

  • PHONE: To file a coverage determination request by phone, call 1-855-791-5302 (TTY 711). Hours: 24 hours a day, 7 days a week.

PLEASE NOTE:  Those not authorized, under state law, to act for you must first sign an appointment of representative form (English) (Español) and either fax to Elixir at 1-877-503-7231 or mail it to the below address:

Elixir
Attn: Coverage Determinations
2181 E. Aurora Road, Suite 201
Twinsburg, OH 44087

How long it takes for a coverage determination decision

The decision about whether your drug will be covered can be a standard decision, made within 72 hours or an expedited decision, made within 24 hours.

Note: The decision time frame begins once the plan receives the request for standard prior authorizations. If the request is for a formulary exception (i.e. non-formulary, quantity limits and tiering exception requests), the decision time frame begins when the plan receives your doctor’s supporting statement.

An expedited decision will only be granted if your doctor confirms that waiting 72 hours could seriously harm your health or compromise your ability to regain maximum function.

If your request for an expedited decision is made by or supported by your doctor, we will automatically follow the 24-hour time frame. If you make the request yourself and we do not grant it, the standard 72-hour time frame will apply.

If we deny your expedited review by phone and you disagree with our decision, you can ask for a 24-hour expedited grievance at that time. Otherwise, we’ll send a letter within 3 calendar days explaining how to file the expedited grievance. It also will explain that we will automatically give you an expedited decision if you get the prescribing doctors support for an expedited review.

How to ask us to pay for a prescription drug you already received

You can ask us to pay for our share of the cost of a drug you have already received where you did not use your Care N’ Care prescription drug benefits.  This is called a Part D Direct Member Reimbursement request.  For information on situations in which you may ask us for reimbursement of prescription drugs, please see your Evidence of Coverage which can be downloaded on the Plan Documents page.

To request reimbursement, please download the Direct Member Reimbursement Form (English | Español) and follow the instructions to complete the form.  Submit the form AND the original paid pharmacy receipts to one of the following:

  • BY MAIL:

Elixir – DMR
8935 Darrow Rd
P.O. Box 1208
Twinsburg, OH 44087

  • BY FAX: Fax your request to Elixir at 866-646-1403

Once we receive your reimbursement request, a decision will be made within 14 calendar days. If approved, payment will be processed and mailed within the same 14 calendar days. If we deny any part of your request, we will provide instructions on how to appeal our decision.  For more information on appealing a denied request, please see your Evidence of Coverage which can be downloaded on the Plan Documents page. For questions regarding the process or status of your request, call the Direct Member Reimbursements Department at Elixir, Care N’ Care’s pharmacy benefit manager, at this toll-free number: 1-800-361-4542.

Status requests

For questions regarding the process or status of a coverage determination or reimbursement request, you, your physician or your appointed representative should call Elixir, Care N’ Care’s pharmacy benefit manager, at this toll-free number: 1-855-791-5302 / (TTY: 711).

If you require additional assistance, please contact your Care N’ Care Customer Experience Team at 1-877-374-7993 (TTY 711), October 1 – March 31, 8 am – 8 pm, (CST) seven days a week or April 1 – September 30, 8 am – 8 pm (CST), Monday through Friday or send an email to yourteam@cnchealthplan.com.

Complaints and disenrollment

If you have a complaint, you can complain to Medicare. You can also end your enrollment. To do that, refer to the information about disenrollment on the Your Rights page.

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