Form Instructions
Coverage Determinations
A coverage determination is HMSA’s initial decision about whether we will
provide coverage for a Part D prescription drug.
Standard decision – The timeframe we have to make a decision
after we receive your request depends on whether you have already received your
prescription drug or you are waiting to receive your prescription drug. Refer to
your Evidence of Coverage for detailed information about the standard decision process
for a coverage determination.
Fast decision – We must notify you by telephone and in writing
of our decision within 24 hours if you or your doctor believes that waiting for
a standard decision could seriously harm your health or your ability to function.
Refer to your Evidence of Coverage for detailed information about the fast decision process
for a coverage determination.
Instructions
To request a coverage determination, contact Medco.
Call
1 (800) 753-2851 for standard and fast decisions, and formulary and utilization management
exceptions
1 (800) 841-5409 for tier exceptions
These toll-free numbers are available 24 hours a day, seven days a week. These numbers
are not Customer Service telephone numbers.
TTY
1 (800) 716-3231
This number requires special telephone equipment and is only for people who have
difficulties with hearing or speaking.
Fax
1 (888) 235-8551, or after business hours, call the toll-free numbers above. Be
sure to ask for a "fast," "expedited" or "24-hour" review.
Write
HMSA Medicare Reviews
Medco Health Solutions, Inc.
P.O. Box 630367
Irving, TX 75063-0118
Your physician or your pharmacist can also request a coverage determination on your
behalf by calling the numbers above.
HMSA accepts oral requests for coverage determinations and does not require
a written request. However, Medicare provides model forms for members
and for providers that list the type of information needed to complete a coverage
determination request. You may use these forms as a reference.
Medicare Coverage Determination Request Form for plan members
Coverage Determination Request Form for physicians (coming soon)
Medicare Model Coverage Determination Request Form
for plan members
Model Coverage Determination Request Form for physicians
If you choose to use the Medicare model form instead of calling the toll-free number,
please print out the form and complete your portion. Mail or fax it to Medco at the
address or number below.
- Fill out your name, telephone numbers, and HMSA number.
- Fill out your physician’s name and contact information.
- Choose the type of coverage determination request.
- If this is a request for a "fast decision," check the box marked "I
need an expedited coverage determination."
- HMSA Medicare Reviews
HMSA Medicare Reviews
Medco Health Solutions, Inc.
Irving, TX 75063-0118
Or fax to: 1 (888) 235-8551
