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Part D Prescribed Drugs Prior-Authorization, Coverage Determination, and Exceptions

Information Last Updated: 11/13/2018

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Prior-Authorization


As a Brand New Day member you can request a prior-authorization for a specific prescribed drug. If you wish to submit a prior authorization for your Part D coverage, please contact the Brand New Day Pharmacy Services Department at 866-255-4795 ext. 2012.
 

Coverage Determinations and Re-Determinations


A coverage determination is any determination (i.e. an approval or denial) made by Brand New Day regarding your Medicare Part D prescription drug coverage. Your requests for Part D coverage determination may include:

Asking whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on the Plan’s List of Covered Drugs (Formulary) but requires our approval before it is covered.)

Asking us to pay for a prescription drug you already bought.

Asking us for an exception. (If a drug is not covered in the way you would like it to be covered, you can ask the Plan to make an “exception.”)

Examples include:

  • Asking for coverage of a drug that is not on the drug list
  • Asking to pay a lower cost-sharing amount for a covered non-preferred drug
  • Asking us to remove the extra rules and restrictions on the Plan’s coverage for a drug such as:
  • Being required to use the generic version of a drug instead of the brand name drug
  • Getting plan approval in advance before we will agree to cover a drug for you
  • Quantity Limits

 

Exceptions and Grievance & Appeals

Important Inform​ation to Know About Asking for Exceptions

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. Your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception.


What to Do

You (or your representative or your doctor or other prescriber) may use the form below to submit your request for a Part D Coverage Determination:

Medicare Prescription Drug Determination Request Form

Please note: If you do not use this form, you will need to provide us the same information indicated in the form so we can process your request in a timely manner.

To start your Part D Coverage Determination request you (or your representative or your doctor or other prescriber) should contact MedImpact:

MedImpact Contact
Call: 1-800-788-2949, TTY 711
24 hours a day, 7 days a week
Mail: MedImpact Healthcare Systems, Inc.
Attn: Client Services
10181 Scripps Gateway Court
San Diego, CA 92131
Fax: 1-858-689-0207
Website: www.MedImpact.com

For additional assistance in making your Part D Coverage Determination request you may call Brand New Day Pharmacy Services Department at:

1-866-255-4795 ext. 2012

TTY: 711

To find out more about the Part D Coverage Redetermination Process, please refer to your Evidence of Coverage (EOC) -- see Chapter 9, Section 6: “Your Part D prescription drugs: How to ask for a coverage decision or make an appeal” or call Brand New Day Member Services at the number(s) listed above.