Coverage Determination

Coverage Determination

A request for coverage determination is when you ask for an exception to the RiverSpring Star (HMO SNP) Drug Coverage, which include requests for exceptions to our formulary, or prior authorization, step therapy, and quantity limit requirements. You can ask us for a coverage determination, for example, if:

  • You want us to make an exception to cover a drug not on the Drug List.
  • You want us to pay for a medication that you already bought.
  • You want us to waive a restriction on our coverage for a drug.

The decision that we make regarding your request is called a coverage determination. If your request is denied, you can then ask us to change our decision, and request an Appeal or plan redetermination. You cannot request an appeal if we have not issued a coverage determination.

How to Request a Coverage Determination

You, or your appointed representative, or the prescriber may request a coverage determination by calling RiverSpring Star (HMO SNP) Pharmacy Services, at 1-855-898-1482, 24 hours a day, 7 days a week (for TTY/TDD, call 711), or by fax to 1-855-898-1483.

When you request an exception, your physician or other prescriber must provide a statement to explain the medical reasons to support your request. This supporting statement from your physician or prescriber must be sent to us at:

RiverSpring Star (HMO SNP) Pharmacy Services
1 Campus Martius, Suite 750
Detroit, MI 48226

Or you may fax it to 1-855-898-1483.

A standard coverage determination will be made within 72 hours. If you or your physician believe that waiting for a standard decision could seriously harm your health or your ability to function, you can ask for an expedited or fast determination, which will be made within 24 hours.

You can also submit a Part D Coverage Determination Request form online by visiting our Pharmacy Benefit Manager’s website.

Appeal

You have the right to appeal if we issued a decision to deny your request for coverage.

If you want to appeal you must request your appeal within 60 calendar days after the date of the first denial. If you need more time than the 60 days, we can give you more time if you have a good reason for missing the deadline.

You, or your appointed representative, or the prescriber may request an expedited appeal or standard appeal by calling RiverSpring Star (HMO SNP) Pharmacy Services at 1-855-898-1482, 24 hours a day, 7 days a week, or fax a request to 1-855-898-1483. You may also send your request for an appeal to:

RiverSpring Star (HMO SNP) Pharmacy Services
1 Campus Martius, Suite 750
Detroit, MI 48226

A standard appeal decision will be made within 7 calendar days after we receive your appeal. If you or your physician believes that waiting for a standard appeal decision could seriously harm your health or your ability to function, you can ask for an expedited or fast appeal, which will be decided within 72 hours after receipt of your appeal.

For more information regarding coverage determinations and appeals, see the
Evidence of Coverage.

The Request for Medicare Prescription Drug Coverage Determination Form is available from CMS.

In your written request please include your name, address, member ID number, the reason(s) for appealing, and any evidence you wish to attach. If your appeal relates to a decision by us to deny a drug that is not on our formulary your prescriber must indicate that all the drugs on any tier of our formulary would not be as effective to treat your condition as the requested off-formulary drug or would harm your health. We will then review your case and give you a decision.

If any of the prescription drugs you requested are still denied you can request an independent review of your case by a reviewer outside of RiverSpring Star (HMO SNP). If you disagree with that decision you will have the right to further appeal. You will be notified of your appeal rights if this happens.

You can also submit a Part D Coverage Determination Request form online by visiting our Pharmacy Benefit Manager’s website.

Last updated on June 6, 2018