Coverage Determination Process:

If your physician or pharmacist tells you a certain prescription requires a prior authorization or is exceeding a coverage limit, you may fill out the coverage determination form below and VillageHealth will assist in having your physician send medical justification to Express Scripts to make a decision on whether to cover your request. Otherwise you may contact VillageHealth Member Services at 1-877-586-1648, 7:00 a.m. - 8:00 p.m., 7 days a week. (TTY Users: 1-866-525-7833) for additional assistance in making this request.

A decision about whether VillageHealth will cover a Part D prescription drug can be a “standard” coverage determination that is made within the standard timeframe typically within 72 hours. You may ask for a fast decision only if your physician believes that waiting for a standard decision could seriously harm your health or your ability to function. Once a decision has been made, Express Scripts will send a letter to you and your physician regarding the decision of the coverage determination.

If you would like VillageHealth to make a decision on a Part D drug, such as a formulary or tier exception, you will need to complete a Coverage Determination Request Form. To find instructions on how to complete a Coverage Determination Request Form, click here.





If your request is about an unfavorable Coverage Determination we have issued, you will need to complete a Re-detemination/Appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.

Note: You cannot request a Re-determination/Appeal if we have not issued a Coverage Determination.

To find instructions on how to complete a Re-determination/Appeal Request, click here.





QUESTIONS?:
You can find detailed information regarding the Grievance and Appeal process in your Evidence of Coverage booklet, Section 12 called "Appeals and Grievances: What to do if you have complaints about your Part D prescription drug benefits".

You may also call Member Services at 1-877-586-1648 from 7:00 a.m. - 8:00 p.m., seven days a week for assistance with problem solving related to your Part D benefits (TTY Users Should Call: 1-866-525-7833) or by Fax: 1-562-989-0958.

You can also mail your request to: VillageHealth
P.O. BOX 22644
Long Beach, CA 90801-5644
Attn: Grievance and Appeals Department


Member Coverage Determination Link