Coverage Determination

A coverage determination is an initial coverage decision made by Inter Valley Health Plan regarding your Medicare Part D prescription drug. Coverage determinations you can request about your Part D drugs include:

      1. You can ask us to pay for a prescription drug you already bought and you believe may be covered;
      2. 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.)
      3. 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:
               A. Asking us to cover a drug that is not on the formulary drug list
               B. Asking to pay a lower cost-sharing amount for a covered non-preferred drug
               C. Asking us to remove the extra rules and restrictions on the Plan’s coverage
                    for a drug such as:
                         1. Being required to use the generic version of a drug instead of the
                             brand name drug
                         2. Getting Plan approval for a drug when the prior authorization criteria
                              have been met
                         3. Quantity Limits
 

Important Information to Know About Asking for Exceptions

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. Your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception.


Important Information to Know About Asking for Exceptions

You (or your representative), your doctor or other prescriber may submit a request for a Part D coverage Determination by using the form below:  (If you do not use this form: you will need to provide us the same information indicated in the form so we are able to process your request in a timely manner)

Click here to print out a copy of Inter Valley Health Plan's Exception Form.

To start the Part D Coverage Determination process, you (or your representative), or your doctor or other prescriber should contact National Pharmaceutical Services (NPS). You may:

  • Call NPS at 1-866-632-7890, 24 hours a day, 7 days a week. TTY users: 1-866-706-4757.
  • Fax your request to: 1-866-632-7946 (Attention: Clinical Team)
  • Email your request to: priorauth@pti-nps.com
  • Mail your request to:
    PTI-NPS
    Coverage Determinations
    P. O. Box 407, Boise Town, NE 68010

To find out more about the Part D Coverage Redetermination Process, please refer to your Evidence of Coverage (EOC) -- see chapter 9, Section 6: "How to ask for a coverage decision or make an appeal." Or call Member Services at the number(s) listed above.
 

How We Processes Coverage Determination Requests

For requests for benefits that do not involve exceptions, the Plan must provide notice of its decision within 24 hours after receiving an expedited request or 72 hours after receiving a standard request. The initial notice may be provided orally so long as a written follow-up notice is mailed to you within 3 calendar days of the oral notification.

For requests for benefits that involve exceptions, the adjudication timeframes do not begin until your doctor/prescriber submits his or her supporting statement to the Plan.

For payment requests, including payment requests that involve exceptions, the Plan must provide written notice of its decision (and make payment when appropriate) within 14 calendar days after receiving a request.

If the coverage determination is unfavorable, the decision will contain the information needed to file a request for redetermination with the Plan

 

 


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