A Coverage Determination is any decision made by a
Medicare Part D plan regarding payment or coverage benefits to which a Medicare plan enrollee
believes he or she is entitled.
More specifically, a coverage determination is a Medicare drug plan's first decision about the services a member can receive as part of the plan's Medicare prescription drug coverage.
This can include a decision:
More specifically, a coverage determination is a Medicare drug plan's first decision about the services a member can receive as part of the plan's Medicare prescription drug coverage.
This can include a decision:
- whether or not to provide or pay for a drug,
- about a formulary exception request,
- about a member's out-of-pocket costs (cost sharing) for a drug, or
- about whether a member has met a prior authorization (PA) requirement for a requested drug.
- Browse Medicare Part D prescription drug plans
- Browse Medicare Advantage plans (MAPD)
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