If a drug is not covered by Align Senior Care, 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.

A coverage determination may be requested by any of the following:

• You or your 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.

To request a coverage determination, ask your provider or prescriber to visit this page.

Provider or Prescriber instructions:

To request a coverage determination, including an exception, from KeyCare Advantage, visit Navitus to login  to access the form or fill out 

To request a Medicare Prescription Drug Appeal (Redetermination) visit Navitus to login to access the form or fill out the 

Fax or mail the completed form to Navitus at:

(844) 268-9791

KeyCare Advantage
PO Box 908
Addison, TX 75001-0908

You may also contact our Member Services Department at 1-844-206-1205 (TTY 711) and request the fax number for Appeals and Grievances.

Your provider may also request an exception or expedited exception by contacting the Pharmacy Help Desk at 1-866-270-3877 (TTY 711) 24 hours a day, and 7 days a week.

Our plan has seventy-two (72) hours (for a standard request) or twenty-four (24) hours for an expedited request) from the date it gets your request to notify you of its decision.

A coverage determination may be requested for any of the following:

• Covering a Part D drug for you that is not on our plan’s List of Covered Drugs (Formulary).
• If you or your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) 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.

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.

Align Senior Care 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 we say no to your request for an exception, 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”.