Prescription Drug Coverage Appeals
Ochsner Health Plan will send you information that explains your rights called an "Evidence of Coverage" (EOC). Please contact us for questions about your EOC.
As a member, you have the right to ask your plan to provide or pay for a drug you think should be covered, provided, or continued. You have the right to request an appeal if you disagree with your plan's decision about whether to provide or pay for a drug.
Before requesting an appeal, we recommend you take the following actions.
Talk to your prescriber and ask:
- Whether the plan has special coverage rules.
- Whether there are generic, over-the-counter, or less expensive brand-name drugs that could work as well as the ones you're taking now.
Proceed with an exception if
- You or your prescriber believes you need a drug that isn't on your plan's formulary.
- You or your prescriber believes that a coverage rule (like prior authorization) should be waived.
- You think you should pay less for a higher tier (more expensive) drug because you or your prescriber believes you can't take any of the lower tier (less expensive) drugs for the same condition.
- You disagree with your plan’s “at-risk determination” under a drug management program that limits your access to coverage for frequently abused drugs.
For more information on Medicare prescription drug coverage appeals visit: https://www.medicare.gov/medicare-prescription-drug-coverage-appeals
Prescription Drug Coverage Appeal Process
An appeal is a formal way of asking us to review and change a coverage decision we have made. For more information on making an appeal about your Part D prescription drugs, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints).
|Method||Appeals for Part D - Prescription Drugs - Contact Information|
Member Services also has free language interpreter services available for non-English speakers.
|WRITE||Ochsner Health Plan, PO Box 4376, Scranton, PA 18505|