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Farm Bureau Select Rx 2020 Farm Bureau Essential Rx 2020 Farm Bureau Select Rx 2021 Farm Bureau Essential Rx 2021 How Medicare Works Formulary Senior Savings Model Medication Therapy Management (MTM) How to Appoint a Representative Quality Assurance Programs Documents & Forms
Part D Coverage Stages Transition Policy Coverage Determinations Appeals Enrollment/Disenrollment Filing a Grievance Fraud, Waste & Abuse Premium Payment Terms & Conditions Medicare's Extra Help Program

Medicare.gov Resources

Medicare.gov Medicare Complaint Form Medicare Prescription Drug Coverage Determinations Best Available Evidence for Low-Income Subsidy

Coverage Determinations

If your pharmacy tells you a prescription drug is not covered, you can request a coverage determination. You can also request a coverage decision if there is a prior authorization restriction or quantity limit for a drug, or if you feel you are paying more than you should be.

To request a coverage decision, you can:

  1. Call Member Services;
  2. Write to us at: Prior Authorization Department, P.O. Box 25183, Santa Ana, CA 92799;
  3. Fax your request to us at 1-800-572-0531; or
  4. Log on to optumrx.com and submit a request. New users will be required to register.

Your doctor can request a coverage decision for you by:

  1. Calling Member Services.
  2. Writing to us at: Prior Authorization Department, P.O. Box 25183, Santa Ana, CA 92799; or
  3. Faxing a request to us at 1-800-572-0531.

Medicare Part D Coverage Determination Request Form – for use by members and providers. 

A standard coverage determination request will be reviewed and a decision made within 72 hours of receiving your request or your prescribing doctor’s statement.

You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite the decision is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.

 

What happens if we deny your request?

If we deny your request, we will send you a written reply explaining the reasons for denial. You have the right to appeal if you are not satisfied with the initial decision. See the “Making an Appeal” section for more information. You can also click here to visit Medicare’s website for information on how to make an appeal.

For more information from Medicare on how to file a complaint, click here to go to Medicare.gov.

To request information for Aggregate Number of Grievances, Appeals and Exceptions to Grievances please call Member Services.