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Coverage and Exceptions

What is a Coverage Determination?

A coverage determination is any determination (i.e., an approval or denial) made by MCS, with respect to whether to provide or pay for a Part D drug that you believe may be covered by MCS, including a decision related to a Part D drug that is: not on the plan’s formulary; determined not to be medically necessary; provided by an out-of-network pharmacy; or otherwise excluded. This may include decisions concerning tiering exceptions; decisions concerning formulary exceptions; decision on the amount of cost sharing for a drug; or a decision whether you have, or have not, complied with a prior authorization or other utilization management requirement; and the lack of MCS to provide a coverage determination in a timely manner, when a delay would adversely affect the health of the enrollee.

For enrollees and providers

To fill the requested information, you can use our Medicare Part D Coverage Determination Request Form.

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Request for Medicare Part D Coverage Determination (Updated: XXXXX XX, XXXX)

To learn more about the process to request prescription drug coverage determinations and exceptions, press the following link:

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Coverage Determinations and Exceptions

Hospice (Only applies if the patient is in Hospice)

To fill the requested information, you can use our Hospice Information for Medicare Part D Form.

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Request for Hospice Information for Medicare Part D Form (Updated: XXXXX XX, XXXX)

How can you request a Coverage Determination?

You, your representative, or prescriber may make a request. There are several ways to request a coverage determination or an exception.

  1. By calling our Customer Service Call Center at 787-620-2530 (Metro area), 1-866-627-8183 (toll free number) or TTY 1-866-627-8182 (people with hearing disabilities). Our service hours are Monday to Sunday from 8:00 a.m. at 8:00 p.m. from October 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday 8:00 a.m. to 8:00 p.m. and Saturday from 8:00 a.m. to 4:30 p.m.
  2. By sending the written request via Fax at: 1-866-763-9097; OR electronically via My MCS application.
  3. By Mailing request to:
    MCS Advantage, Inc.
    Pharmacy Department
    PO BOX 191720
    San Juan, PR 00919-1720

If you want another individual (such as a family member or friend) to submit an application on your behalf, that individual must be your authorized representative. A completed Authorization of Representation Form CMS-1696 or a written equivalent must be attached to the request. For more information on appointing a representative see Appointment of Representative.

What do you need to include in your request?

You may complete the “Request for Medicare Prescription Drug Coverage Determination” Form or you could include in your request the following information:

  • Your complete name
  • Member ID
  • Prescription Copy
  • Diagnosis
  • Laboratories (if apply)
  • Clinical Justification (if applicable)

How can you request an Exception Request?

If you are taking a drug not included in the MCS Classicare Formulary, and you cannot use an alternative drug in the list due to efficacy or side effects, you may request an exception to the Formulary. There are three types of Exception Requests:

  1. Formulary Exception: you can ask us to cover a Part D drug even if it is not on our formulary.
  2. Formulary Edit Exception: you can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, MCS Classicare limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
  3. Tiering exception: you can also ask us to provide a higher level of coverage for your drug. If your drug is included in our highest tier within the formulary, you can ask us to cover it at the cost-sharing amount that applies to drugs in the lowest tier subject of the tiering exceptions process tier, instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the cost sharing specialty drugs tier.

Generally, MCS Classicare will only approve your request for an exception if the alternative drugs are included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

To request an exception to a non-formulary drug, to your copayment level or to a utilization restriction on the drug, you must also submit a written request from your doctor supporting your request to the following address:

Pharmacy Department:
Fax: 1-866-763-9097
Mailing Address: MCS Advantage, Inc.
Pharmacy Department
PO BOX 191720
San Juan, PR 00919-1720

MCS will make a decision on the request in a period of 72 hours (standard request) after receiving your doctor’s supporting statement.

If you believe that the 72-hour review period may adversely affect your health, you may request an expedited (fast) decision. To request it, simply specify in your request that an expedited review is necessary, and a decision will be issued within a period of 24 hours from the receipt of your doctor’s supporting statement.

If the request is denied; how can I appeal the decision?

You, your representative, doctor, or other prescriber should contact us and make your appeal. Submit a written request or call us. You may use the "Request for Redetermination of Medicare Prescription Drug Denial" Form. This form may be sent to us by mail or fax:

Address:
MCS Advantage, Inc.
Pharmacy Department
PO Box 191720
San Juan, PR 00919-1720

Fax:
1-866-763-9097
787-200-2858

Expedited appeal requests can be made by phone at 1-866-627-8183 (Toll free number) (TTY: 1-866-627-8182).

  • MCS will make a decision on the case in a period of 7 calendar days (standard request) after receiving the appeal request
  • If you believe that the 7 calendar days review period may adversely affect your health, you may request an expedited decision. To apply, simply state in the request that an expedited review is necessary, and a decision will be issued within a period of 72 hours or less from the receipt of the request.

To learn more about how to request a coverage determination, an exception, or an appeal, refer to your product Evidence of Coverage.

See the Evidence of Coverage, Chapter 9 under “What to do if you have a problem or complaint (coverage decisions, appeals, complaints)”

How to obtain an aggregate number of grievances, appeals, and exceptions filed with MCS Classicare?

As a member of our plan, you have the right to get several kinds of information from us. This includes information about the number of grievances and appeals made by members and the plan’s performance ratings, including how it has been rated by plan members and how it compares to other Medicare Advantage health plans. If you want any of the following kind of information, please call our Customer Service Call Center at 787-620-2530 (Metro area), 1-866-627-8183 (toll free number) or TTY 1-866-627-8182 (people with hearing disabilities). Our service hours are Monday to Sunday from 8:00 a.m. to 8:00 p.m. from October 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday 8:00 a.m. to 8:00 p.m. and Saturday from 8:00 a.m. to 4:30 p.m. Also, you can request it by fax at 787-620-7765 or by mailing: MCS Advantage, Inc., Grievances and Appeals Unit, PO Box 195429 San Juan PR 00919.

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