Helpful forms

The following forms have been developed to assist members and physicians when requesting a prescription drug coverage determination, exception, redetermination or grievance request.

Please complete all requested sections and fields. If you need assistance completing forms, please contact Security Health Plan Customer Service at 1-877-998-0998. We are open 8 a.m. to 8 p.m., 7 days a week, Oct. 1-March 31; and Monday through Friday 8 a.m. to 8 p.m., April 1-Sept. 30. If you are hearing- or speech-impaired please call TTY 711.

• Request for Coverage Determinations and Exceptions (Enrollees) (fillable)
• Redetermination Request Form (fillable)
• Appointment of Representative Form (fillable)

Complete forms can be sent to us by fax, mail or via the plan's website.

Fax: 715-221-9989

Address:

Security Health Plan
Attn: Pharmacy Department/UM Technician
1515 North Saint Joseph's Avenue
PO Box 8000
Marshfield, WI 54449-8000

Website:

How to initiate a request using electronic submission

• Click on the fillable form that is applicable to your request.
• Fill out the form by typing the necessary information into the required fields.
• Once the form is complete, review it to make sure it is filled out to the best of your knowledge.
• Save  the form to your computer.
• Submit the completed form by sending it as an attachment to the following email address:  SHPRx-mfld@sanfordhealth.org

Appointment of representation

If you need help to understand or follow the coverage determination, exceptions, appeals and grievance processes, you can get assistance from a friend, lawyer or someone else. If you qualify, you can contact groups such as legal-aid services that can help you find a lawyer or give you free legal services.

An appropriate signed form must be on file with Security Health Plan to request a coverage determination (including an exception), redetermination or grievance from someone other than the member, their prescribing doctor or other prescriber.

 

Appointment of Representative Form (fillable)

You and your representative must sign the Appointment of Representative Form and return it to Security Health Plan for it to be valid.  The valid form is good for one year from the date it was signed by both parties.  An Appointment of Representative Form is not required if another legal document is already on file; such as a Power of Attorney for Health Care.

 

To appoint a representative by fax or mail:

 

Fax: 715-221-9989

 

Address:

Security Health Plan 
Attn: Pharmacy Department/UM Technician
1515 North Saint Joseph Avenue
 P.O. Box 8000
Marshfield, WI 54449-8000

 

If you have questions, you, your representative or prescriber can call Customer Service at 1-877-998-0998. We are open 8 a.m. to 8 p.m., 7 days a week, Oct. 1-March 31; and Monday through Friday 8 a.m. to 8 p.m., April 1-Sept. 30. If you are hearing- or speech-impaired please call TTY 711.

A coverage determination is any request to cover a part D drug that is not on our list of covered drugs or is on our list of covered drugs but requires you to get approval from us before we will cover it for you.

 

Prescription drug coverage determination process

 

Whenever you ask for prior authorization or an exception to the utilization management requirements, the first step is called requesting a coverage determination. When we make a coverage determination, we are making a decision whether to provide or pay for a Part D drug and what your share of the cost is for the drug.

 

The following are examples of coverage determinations:

• You ask us to pay for a prescription drug you have already received. This is a request for a coverage determination about payment.
• You ask us to provide coverage for a drug that requires a prior authorization.
• You ask that we reimburse you for a purchase you made from an out-of-network pharmacy. In some situations, Security Health Plan will cover out-of-network purchases, including drugs provided to you in a physician’s office.

How do I request a coverage determination?

You, your representative or prescriber can submit or request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination.

You, your representative or prescriber can submit or request a coverage determination by phone, fax, mail or through the plan’s website.

 

Phone: 1-877-998-0998<br /> TTY: 711 

Fax: 715-221-9989

 

Address:

Security Health Plan

Attn: Pharmacy Department/UM Technician

1515 North Saint Joseph Avenue

P.O. Box 8000

Marshfield, WI 54449-8000

 

Website:

To initiate a coverage determination request using electronic submission:

• Click on the fillable form below.
• Fill out the form by typing the necessary information into the required fields.
• Once the form is complete, review it to make sure it is filled out to the best of your knowledge.
• Save the form to your computer
• Submit the completed form by sending it as an attachment to shprx-mfld@Sanfordhealth.org

Request for Coverage Determination and Exceptions

If you have questions, you, your representative or prescriber can call Customer Service at 1-877-998-0998. We are open 8 a.m. to 8 p.m., 7 days a week, Oct. 1-March 31; and Monday through Friday 8 a.m. to 8 p.m., April 1-Sept. 30. If you are hearing- or speech-impaired please call TTY 711.

Security Health Plan has a standard and an expedited procedure for making coverage determinations. The following is an explanation of each process.

 

Standard prescription drug coverage determination process

 

You, your representative or prescriber can submit or ask for a standard coverage determination. We must give you a decision no later than 3 calendar days or 72 hours after we receive your request. If your request is for payment of a drug you’ve already received, we’ll give you a written decision within 14 days.

 

Generally, we must give you our decision no later than 72 hours after we have received your request, but we will make it sooner if your health condition requires. However, if your request involves a request for an exception (including a formulary exception, tiering exception or an exception from utilization management rules – such as dosage or quantity limits) we must give you our decision no later than 72 hours after we have received your physician's "supporting statement," which explains why the drug you are asking for is medically necessary. If you are requesting an exception, you should submit your prescribing physician's supporting statement with the request, if possible.

 

You and your prescribing physician will be notified of the decision, whether favorable or adverse. If Security Health Plan first notifies you of an adverse decision orally, we will mail written confirmation to you within 3 calendar days of the oral notification. The written notice will also state the specific reason for the denial in understandable language and contain all of the applicable Medicare appeals language to ensure you are informed of your right to file a redetermination (appeal). If we fail to meet the 3 calendar days or 72 hour deadline, we will automatically forward your request to the independent review entity (IRE) designated by the Centers for Medicare and Medicaid Services (CMS). The IRE is a reviewer outside of Security Health Plan and will issue a determination.

 

Expedited prescription drug coverage determination process

 

You, your representative or prescriber can request an expedited coverage determination. An expedited request can be submitted orally or in writing to Security Health Plan and your prescribing physician may provide oral or written support for your request for an expedited coverage determination. A request made or supported by your prescribing physician will be expedited if your physician indicates that applying the standard timeframe for making a determination might seriously jeopardize your life or health or your ability to regain maximum function.

 

When Security Health Plan determines that a request qualifies for expedited handling, we will make our determination as expeditiously as your health condition requires but no later than 24 hours after receiving the request, or for an exceptions request upon receipt of your physician's supporting statement.  You and your prescribing physician will be notified of the decision, whether favorable or adverse. If Security Health Plan first notifies you of an adverse decision orally, we will mail written confirmation to you within 3 calendar days of the oral notification. The written notice will also state the specific reason for the denial in understandable language and contain all of the applicable Medicare appeals language to ensure you are informed of your right to file a redetermination (appeal).

You, your representative or prescriber can submit or request an expedited coverage determination by phone, fax, mail or through the plan’s website as indicated above. If your request is written, the 24 hour review time will not begin until your request is received. A verbal request by telephone is the fastest way to request an expedited coverage determination.

If Security Health Plan determines that your request is not time-sensitive and your health is not seriously jeopardized, Security Health Plan will notify you verbally and in writing, and will automatically begin processing your request under the standard redetermination process. If you disagree and believe the review should be expedited, you may file an expedited grievance with Security Health Plan. The written notice will include instructions on how to file an expedited grievance.

If Security Health Plan fails to make a coverage determination within the 24-hour timeframe, it constitutes an adverse coverage determination. Security Health Plan will send the request to the independent review entity (IRE) designated by the Centers for Medicare and Medicaid Services (CMS) within 24 hours of the expiration of the adjudication timeframe. The IRE will issue a determination. The IRE is a reviewer outside of Security Health Plan.

An exception request is a type of coverage determination that allows you to request coverage on something that normally isn’t covered.

 

The prescription drug coverage exception process

 

You, your representative or prescriber have the right to ask us for an “exception” to our coverage rules.  These are some types of exceptions:

• Formulary exception – a request to cover your drug even if it is not on our formulary.  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.
• Quantity exception – a request to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit 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.
• Tiering exception – a request to provide a higher level of coverage for your drug. For example, if your drug is usually considered a Tier 4 drug, you can ask us to cover it as a Tier 3 drug. This would lower the copayment amount you must pay for the drug.

If you request an exception, your physician must provide a statement to support your request to help us make a decision more quickly. Once the supporting statement is received, a decision will be made to approve or deny your request.

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

A decision by Security Health Plan concerning an exception request constitutes a coverage determination; therefore, all of the coverage determination requirements and timeframes described in the coverage determination process section apply.

If we approve your exception request, our approval is valid for the remainder of the plan year, so long as your doctor continues to prescribe the drug for you and it continues to be safe and effective for treating your condition. If we deny your exception request, you can appeal our decision.

You, your representative or prescriber can file an exception request by phone, fax, mail or through the plan’s website:

 

Phone: 1-877-998-0998
TTY 711

Fax: 715-221-9989

 

Address:

Security Health Plan

Attn: Pharmacy Department/UM Technician

1515 North Saint Joseph Avenue

P.O. Box 8000

Marshfield, WI 54449-8000

 

Website:

To initiate an exception request using electronic submission:

• Click on the fillable form below.
• Fill out the form by typing the necessary information into the required fields.
• Once the form is complete, review it to make sure it is filled out to the best of your knowledge.
• Save the form to your computer
• Submit the completed form by sending it as an attachment to shprx-mfld@Sanfordhealth.org

Request for Coverage Determinations and Exceptions

 

If you have questions, you, your representative or prescriber can call Customer Service at 1-877-998-0998. We are open 8 a.m. to 8 p.m., 7 days a week, Oct. 1-March 31; and Monday through Friday 8 a.m. to 8 p.m., April 1-Sept. 30. If you are hearing- or speech-impaired please call TTY 711.

 

The request should include:

• The member name
• Health care provider’s name, address and telephone number
• Prescription drug strength, dosage form and directions
• Diagnosis
• Lab medical data
• The medical reason for the request

The redetermination process, also referred to as an appeal, is used to review an adverse coverage determination made by Security Health Plan on the benefits that you believe you are entitled to receive. This includes a delay in providing or approving drug coverage (when the delay will affect your health), or on any amounts you must pay for drug coverage.

 

The prescription drug standard redetermination (appeal) process

 

When you, your representative or prescribing physician disagrees with the outcome of the initial coverage determination or exception request, he or she may request a standard or expedited redetermination. You have 65 calendar days from the date of our denial notice to request a redetermination.     

 

There are two kinds of redeterminations you can file:

 

Standard Part D Redetermination (7 or 14 days)

 

You, your representative or prescriber can file a standard appeal by phone, fax, mail or through the plan’s website. We must give you a decision no later than:

• 7 calendar days after we receive your request for a drug you have not received.
• If your request is for payment of a drug, you have already received, we will give you a written decision within 14 days.

If we fail to meet the deadlines, we will automatically forward your request to the independent review entity (IRE) designated by the Centers for Medicare and Medicaid Services (CMS). The IRE is a reviewer outside of Security Health Plan and will issue a determination.

 

Expedited Part D Redetermination (72-hour review)

 

You, your representative or prescriber can file an expedited (fast) appeal:

• If any doctor asks for an expedited appeal for you, or supports you in asking for one, and indicates that waiting for 7 days could seriously harm your health, we will automatically expedite your appeal.
• If you ask for an expedited appeal without support from a doctor, we will decide if your health requires an expedited appeal. We will notify you if we do not give you an expedited appeal and will decide your appeal within 7 days.

You, your representative or prescriber can file an expedited (fast) appeal by phone, fax, mail or through the plan’s website as indicated above. A verbal request by telephone is the fastest way to file an expedited request. We must decide on an expedited appeal no later than 72 hours after we get your appeal. If we fail to meet the 72-hour deadline, we will automatically forward your request to the independent review entity (IRE) designated by the Centers for Medicare and Medicaid Services (CMS). The IRE is a reviewer outside of Security Health Plan and will issue a determination.

 

What do I include with my redetermination request?

 

You should include your name, address, member identification number, the reasons for appealing and any evidence you wish to attach. You may send in supporting medical records, doctors’ letters or other information that explains why we should provide the service. Call your doctor if you need this information to help you with your appeal.

 

How do I file a redetermination request?

 

You, your representative or prescriber can file a redetermination request by phone, fax, mail or through the plan’s website.  A verbal request by telephone is the fastest way to file an expedited (fast) request.

 

Phone: 1-877-998-0998

TTY 711

Fax: 715-221-9989

Address:

Security Health Plan

Attn: Pharmacy Department/UM Technician

1515 North Saint Joseph Avenue

PO Box 8000

Marshfield, WI 54449-8000

 

Website:

To initiate a redetermination request using electronic submission:

• Click on the fillable form below.
• Fill out the form by typing the necessary information into the required fields.
• Once the form is complete, review it to make sure it is filled out to the best of your knowledge.
• Save the form to your computer
• Submit the completed form by sending it as an attachment to shprx-mfld@Sanfordhealth.org

Redetermination Request Form

 

If you have questions, you, your representative or prescriber can call Customer Service at 1-877-998-0998. We are open 8 a.m. to 8 p.m., 7 days a week, Oct. 1-March 31; and Monday through Friday 8 a.m. to 8 p.m., April 1-Sept. 30. If you are hearing- or speech-impaired please call TTY 711.

 

What happens next?

 

After we receive your appeal, we will review your case and give you a decision. If we continue to deny any of the prescription services you requested and you disagree with that decision, you will have further appeal rights. You have 65 days to file a written appeal with the IRE.  This is called a reconsideration and you can use the Request for Reconsideration form below. If you disagree with the IRE decision, you will have the right to further appeal. You will be notified of these appeal rights if this happens.

 

Request for Reconsideration of Medicare Prescription Drug Denial

 

A grievance is any complaint other than one that involves a coverage determination or redetermination. You would file a grievance if you have any type of problem with Security Health Plan or one of our network pharmacies that does not relate to coverage for a prescription drug. For example, you would file a grievance if you have a problem with things such as waiting times when you fill a prescription, the way your network pharmacist or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of a network pharmacy.

Prescription drug plan grievance process

Our grievance process is designed to address a member’s coverage issues, complaints and problems. Grievances must be filed in writing within 60 days of the event or incident. A grievance about quality of care can be filed with Security Health Plan or the Quality Improvement Organization (QIO). Grievances will be resolved as expeditiously as the case requires based on the member’s health status. For standard grievances, notifications must be delivered no more than 30 days from the date of receipt. Security Health Plan or the member can take up to a 14 day extension. If Security Health Plan initiates an extension, the member will be notified either orally or in writing and the letter must provide the reason for the delay. For expedited grievances, notifications must be delivered no later than 24 hours from the date of receipt.

Security Health Plan will track all oral and written grievances received, including the date received, type of grievance and final disposition of the grievance, and the date the member was notified of the final outcome or resolution.

You, your representative or prescriber can file a grievance by phone, fax or mail.

 

Phone: 1-877-998-0998
TTY 711

Fax: 715-221-9989

Address:

Security Health Plan
Attn: Medicare Plan Grievance/Pharmacy Services
1515 North Saint Joseph Avenue

P.O. Box 8000
Marshfield, WI 54449-8000

If you or your physician have questions regarding the grievance process, to file a grievance or check on the status of your grievance, you may contact Customer Service at 1-877-998-0998. We are open 8 a.m. to 8 p.m., 7 days a week, Oct. 1-March 31; and Monday through Friday 8 a.m. to 8 p.m., April 1-Sept. 30. If you are hearing- or speech-impaired please call TTY 711.