Making a Request

Who may ask for a coverage determination?

You, your doctor or other prescriber or someone you name as your representative can ask us for a coverage determination. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor, or anyone else to act for you. Some other persons may already be authorized under State law to act for you. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. This statement must be sent to the plan by mail or by fax. You may also call Member Services to learn how to name your appointed representative.

You also have the right to have an attorney ask for a coverage determination on your behalf. You can contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer.

You may request a prescription drug coverage determination by submitting the Coverage Determination Request Form by mail or by fax.

Mailing Address:
Leon Medical Centers Health Plans
Part D Department
8600 NW 41st Street, Suite 201
Doral, FL 33166

Fax: (305) 229-7462

You may also ask for a coverage determination by calling Member Services, toll free at 1-866-393-5366. TTY/TDD users call 711, 7 days a week, from 8:00am to 8:00pm or by using our Online Coverage Determination Request Form. You may also send your request via secured email at LMCHPPARTD@healthspring.com.


Asking for a “standard" or "fast" coverage determination

A decision about whether we will cover a Part D prescription drug can be a “standard" coverage determination that is made within the standard timeframe (typically within 72 hours) or it can be a “fast" coverage determination that is made more quickly (typically within 24 hours). A fast decision is sometimes called an “expedited coverage determination.”

You can ask for a fast decision only if you or your doctor believe that waiting for a standard decision could seriously harm your health or your ability to function.

  • If your doctor asks for a fast decision for you, or supports you in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you a fast decision.

  • If you ask for a fast coverage determination without support from a doctor, we will decide if your health requires a fast decision. If we decide that your medical condition does not meet the requirements for a fast coverage determination, we will send you a letter informing you that if you get a doctor’s support for a fast review, we will automatically give you a fast decision. The letter will also tell you how to file a “grievance” if you disagree with our decision to deny your request for a fast review.

If we deny your request for a fast coverage determination, we will give you our decision within the 72 hour standard timeframe.

The standard time frame for a coverage determination about payment for a drug you have already received is 14 calendar days. (Fast decisions apply only to requests for Part D drugs that you have not received yet. You cannot get a fast decision if you are requesting payment for a Part D drug that you already received.)