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Coverage Determination

Whenever you ask for a Part D prescription drug benefit, the first step is called requesting a coverage determination.

A coverage determination is a type of coverage decision our plan makes about the coverage or the amount our plan will pay for your Part D prescription drugs. This includes asking our plan to make an exception to the way our drug is covered.

The following are examples of coverage determinations:

  • You ask us to pay for a prescription drug you have already received. This is a request for a coverage determination about payment.

  • You ask for a Part D drug that is not on your plan's list of covered drugs (called a "formulary"). This is a request for a "formulary exception."

  • You ask for an exception to our plan’s utilization management tools - such as prior authorization, quantity limits, or step therapy requirements. Requesting an exception to a utilization management tool is a type of formulary exception.

  • You ask for a non-preferred Part D drug at the preferred cost-sharing level. This is a request for a "tiering exception."

  • You ask that we reimburse you for a purchase you made from an out-of-network pharmacy. In certain circumstances, out-of-network purchases, including drugs provided to you in a physician’s office, will be covered by the plan.

When we make a coverage determination, we are giving our interpretation of how the Part D prescription drug benefits that are covered for members of Leon Cares apply to your specific situation. Any amendments you may receive describe the Part D prescription drug benefits covered by Leon Cares, including any limitations that may apply to these benefits.