A coverage determination is a decision a health plan makes about whether it covers a drug prescribed for a member. The plan also decides the amount, if any, it must pay for the drug. If a plan denies a member coverage for a drug his or her physician prescribes, the member can request a coverage determination.
If the member is not satisfied with the outcome of a coverage determination, the member can appeal the decision by requesting a redetermination. When a member requests a redetermination, the plan will review the coverage determination to see if the plan followed all the rules properly.
To request a coverage determination or redetermination, you can choose one of these options: