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What is a coverage determination?
A coverage determination is a decision made by Simpra Advantage (not the pharmacy) about your prescription drug benefits, including:
- Whether a drug is covered
- Whether you have met all the requirements for getting a requested drug
- How much you’re required to pay for a drug, and
- Whether to make an exception to a plan rule when you request it
What is an exception?
If a drug is not covered by Simpra Advantage, you can ask the plan to make an “exception.” An exception is a type of coverage decision, similar to other types of coverage decisions. If we turn down your request for an exception, you can appeal our decision.
When you ask for an exception, your doctor or another prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request.
What is a good cause exception?
You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of good cause for missing the deadline may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.
Who can request a coverage determination / exception?
A coverage determination, including exceptions, may be requested by any of the following:
- You or your authorized representative may request a coverage determination.
- Your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) can request a coverage determination for you on your behalf.
Where can a coverage determination/exception be filed?
To request a coverage determination, ask your provider or prescriber to visit the Provider Documents page on this website and download the Prescription Drug Determination Request form.
Fax or mail the completed form to Navitus at:
PO Box 1039
Appleton, WI 54912-1039
You may also email Appeals and Grievances at A_G@simpra.com.
When can a coverage determination / exception be requested?
A coverage determination may be requested for any of the following:
- Covering a Part D drug for you that is not on the list of covered drugs (formulary).
- If your health care provider or prescriber believes you need a drug that isn’t on the list of covered drugs (formulary).
- If your network pharmacy can’t fill a prescription as written.
- To remove a restriction for a covered drug.
- If you or your prescriber believe that a coverage rule (such as prior authorization) should be waived.
- Changing coverage of a drug to a lower cost-sharing tier.
- If you think you should pay less for a higher-tier drug because you or your prescriber believe you can’t take any of the lower-tier drugs for the same condition.
- Request for payment.
Important things to know about asking for exceptions
Your doctor will work with you to request an exception. Your doctor or other prescribers will be requested to provide the clinical rationale for the exception.
Simpra Advantage can accept or deny your request.
If we approve your request for an exception, our approval usually is valid until the end of the plan year. This is true if your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.
If the request is denied, you can ask for a review of our decision by making an appeal. If your health requires a quick response, you must ask us to make a “fast decision”.