2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 206 · If your pharmacy tells you that your prescription cannot be filled as written, the pharmacy will give you a written notice explaining how to contact us to ask for a coverage decision. Part D coverage decisions and appeals Legal Term An initial coverage decision about your Part D drugs is called a “coverage determination.” A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your drugs. This section tells what you can do if you are in any of the following situations: · Asking to cover a Part D drug that is not on the plan’s List of Covered Drugs. Ask for an exception. Section 6.2 · Asking to waive a restriction on the plan’s coverage for a drug (such as limits on the amount of the drug you can get). Ask for an exception. Section 6.2 · Asking to pay a lower cost-sharing amount for a covered drug on a higher cost-sharing tier Ask for an exception. Section 6.2 · Asking to get pre-approval for a drug. Ask for a coverage decision. Section 6.4 · Pay for a prescription drug you already bought. Ask us to pay you back. Section 6.4 If you disagree with a coverage decision we have made, you can appeal our decision. This section tells you both how to ask for coverage decisions and how to request an appeal. Section 6.2 What is an exception? Legal Terms Asking for coverage of a drug that is not on the Drug List is sometimes called asking for a “formulary exception.” Asking for removal of a restriction on coverage for a drug is sometimes called asking for a “formulary exception.” Asking to pay a lower price for a covered non-preferred drug is sometimes called asking for a “tiering exception.” If a drug is not covered in the way you would like it to be covered, you can ask us to make an “exception.” An exception is a type of coverage decision. For us to consider your exception request, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. Here are three examples of exceptions that you or your doctor or other prescriber can ask us to make: