Medicare Advantage Part D Authorizations, Exceptions, Appeals and Grievances
Your plan has a "formulary" that lists drugs that are covered, and most can be obtained by simply presenting your prescription at a participating pharmacy and paying your part of the cost. A few other drugs need to be authorized in advance for medical necessity, and some drugs are not covered at all. Your formulary generally has at least two drugs in each category, so you should almost always be able to find an alternative that works for you.
This page provides answers to frequently asked questions about procedures for obtaining drugs or filing complaints about your benefits, and we hope you find it useful. Please contact us if you need any additional assistance.
- More about covered drugs and prior authorizations
- More about exceptions
- More about appeals
- More about grievances
Covered drugs and prior authorizations
Q1: How do I know what drugs are covered, and which ones require authorization?
A1: Your formulary will list the drugs that are covered and indicate which drugs require prior authorization.
Comprehensive formulary — a complete list of covered drugs
Q2: How do I get prior authorization for a drug?
A2: Your doctor will typically send us a request, including any clinical information to support it, or you can use the form below. Simply complete the form and submit it to us according to the instructions.
Request for Medicare Prescription Drug Coverage Determination
Q3: How do I know what drugs are not covered on the formulary?
A3: If a drug is not listed on the comprehensive formulary, then it is not covered. Additionally, the following drugs are specifically excluded by the Medicare Part D program, so AdventHealth Advantage Plans does not cover them:
Drugs used for anorexia, weight loss, or weight gain
Drugs used to promote fertility
Drugs used for cosmetic purposes or hair growth
Drugs used for the symptomatic relief of cough and colds
Prescription vitamins & mineral products, except prenatal vitamins & fluoride preparations
Non-prescription drugs
Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee
Drugs used for treatment of sexual or erectile dysfunction, unless such agents are used to treat a condition, other than sexual or erectile dysfunction, for which the agents have been approved by the Food and Drug Administration
Exceptions
Q4: What do I do if my drug isn't on the formulary?
A4: Try to find a covered formulary alternative in the same therapeutic class. If this is not an option and the drug is not excluded under Medicare Part D, you can request an exception as described in A6. (Exceptions are not granted for excluded Part D drugs; See A3 for list of excluded drugs.)
Q5: What if a formulary alternative is not effective or causes adverse effects?
A5: If a formulary alternative is not an option and the drug is not excluded under Medicare Part D, you can request an exception as described in A6. (Exceptions are not granted for excluded Part D drugs; See A3 for list of excluded drugs.)
Q6: How do I request a formulary exception?
A6: The best way is to have your doctor fax a completed request form, along with their supporting statement and any clinical documentation, to our Pharmacy Department at 1-855-328-0061.
You or your doctor can also submit your request online.
Or you can use the form below. Simply complete the form and submit it to us according to the instructions.
Request for Medicare Prescription Drug Coverage Determination (members)
Request for Redetermination of Medicare Prescription Drug Denial (members)
Provider Request for Medicare Prescription Drug Coverage Determination (providers)
Q7: What should be included with the exception request?
A7: A physician's statement indicating why the drug is medically necessary, in addition to clinical documentation supporting the request. To be eligible for an exception, the request must demonstrate that a formulary drug would (1) not be as effective as the drug being requested, (2) would cause adverse effects, or (3) both. When applicable, it should also indicate which other drugs failed or caused adverse effects.
Q8: What if all the required information isn't submitted with the exception request?
A8: If a request is received without all the required documentation, it will be considered "incomplete" and returned to the doctor with a request for information. It will not be reviewed until all the required elements have been submitted, and will be denied if the requested information is not received after 96 hours (4 days).
Q9: If I request an exception with all the required information, will it be approved?
A9: Not necessarily. It will be reviewed by the Pharmacy Departments, and a decision will be based on clinical evidence, your unique medical condition, and characteristics of the drug itself.
Q10: How long will it take to get a decision on my exception request?
A10: A decision will be made within 72 hours (3 days) for complete standard requests, and 24 hours (1 day) if the standard timeframe could jeopardize your health. Your doctor should indicate if the fast timeframe is warranted, and the decision will be made in 24 hours. Contact our Care Team to find out the status of your request.
Q11: How will I know about the plan's decision on my exception request?
A11: If the exception is approved, you and your doctor will receive an approval letter indicating the authorization number and length of coverage. If the request is denied, you and your doctor will receive a denial letter indicating the reason for the decision and how to appeal it if you choose.
Q12: If my exception request is approved, what will my cost-share be?
A12: If a formulary exception is approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
Appeals
Q13: If my exception request is denied, how can I appeal?
A13: If drug coverage is denied, your or your authorized representative can file an appeal by writing to us within 60 days from the denial, telling us why you believe the decision was incorrect. If the situation is urgent and you need a decision quickly, your doctor will automatically be considered your authorized representative and can appeal on your behalf. Expedited appeals will be accepted in writing, or verbally by contacting our Care Team. If the appeal is not urgent, you can file a written appeal, or authorize your physician to act on your behalf in writing, or call our Care Team toll-free at 877-535-8278 or TTY/TTD
relay 1-800-955-8771) weekdays from 8 am to 8 pm and Saturdays from 8 am to noon. From October 1 - March 31, we're available seven days a week from 8 am to 8 pm. If you call after hours, you can leave a message and we'll return your call the next business day. Appeals will be decided within 7 days unless your medical condition warrants an expedited timeframe, in which the appeal will be decided within 72 hours. You will have the right to an external review if the decision is still not in your favor. You can also fax your appeal to 1-855-633-7673.
You or your doctor or representative can also submit your request online (by clicking this link you will be leaving AdventHealth Advantage Plans's web site).
Or you can also use the form below. Simply complete the form and submit it to us according to the instructions.
Q14: If I have been denied coverage for a drug I think should be covered, or don't agree with the amount I was charged, what can I do?
A14: You have the right to appeal as described in A13 .
Grievances
Q15: What can I do if I have a complaint about something other than coverage for a specific drug I requested?
A15: If you are dissatisfied with any aspect of your prescription drug plan, including a decision not to expedite a coverage decision for you, you can file a grievance within 60 days of the incident. We hope that you will call us first about your concern, but if we cannot resolve it for you immediately, you can also send a written grievance along with supporting information to:
Health First Health Plans
PO Box 62378
Phoenix, AZ 85082
To contact us by phone, please call our Care Team toll-free at 877-535-8278 or TTY/TTD relay 1-800-955-8771) weekdays from 8am to 8pm and Saturdays from 8am to noon. From October 1 - March 31, we're available seven days a week from 8am to 8pm. If you call after hours, you can leave a message and we'll return your call the next business day. You can also fax your grievance to 1-833-554-9047.
Q16: What happens after I file a grievance?
A16: Appropriate people at AdventHealth Advantage Plans will investigate your concern and advise you of the outcome of the review within 30 days, unless a 14-day extension is warranted. Your satisfaction is our greatest concern and we will do everything possible to ensure you are treated fairly.
Q17: What if my grievance is related to the quality of care I received?
A17: You can file a grievance with AdventHealth Advantage Plans as described above, and can also file your grievance with the Florida Quality Improvement Organizations (QIO) by contacting them at the following address and telephone number listed below:
KEPRO
5201 W. Kennedy Blvd, Suite 900
Tampa, FL 33609
Toll-free number: 888-317-0751
Fax number: 844-834-7129
Other Appeals and Grievances Information
Please contact our Care Team for information related to the aggregate number of appeals, grievances, and exceptions filed with the Plan, and for information regarding the process or status of your case.
How to contact Medicare
Our Care Team is dedicated to personally solving any problems you may have with us and our providers to your full satisfaction. If you prefer to contact the Centers for Medicare and Medicaid Services (CMS) directly, please visit Medicare's web site:
AdventHealth Advantage Plans is administered by Health First Health Plans. Health First Health Plans is an HMO plan with a Medicare Contract. Enrollment in Health First Health Plans depends on contract renewal.
Y0089_EL9652AH_M | Accepted date: 10/01/2021
Last updated: 10/01/2021