Request A Coverage Determination
What is a coverage determination?
A coverage determination is a decision made by Align Senior Care (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 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.
Who can request a coverage determination / exception?
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.
Where can a coverage determination/exception be filed?
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 Align Senior Care, visit Navitus to login to access the form or print/download the Determination or Redetermination Forms on our Provider Documents page.
Fax or mail the completed form to Navitus at:
Align Senior Care
PO Box 908
Addison, TX 75001-0908
You may also contact our Member Services and request the fax number for Appeals and Grievances.
- California: 1-844-305-3879 (TTY 711)
- Florida: 1-844-788-8935 (TTY 711)
- Michigan: 1-855-855-0336 (TTY 711)
- Virginia/Massachusetts: 1-855-855-0489 (TTY 711)
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.
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 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.
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.
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”.