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Provider Manual

Coverage Determination

Last Updated on January 24, 2019

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 or what the cost share of the drug will be. Coverage determinations include exception requests. You have the right to ask us for an “exception” if you believe your patient needs a drug that is not on our list of covered drugs (formulary) or you believe the patient should get a drug at a lower copayment. If you request an exception, you must provide a statement to support your request.

 The following are examples of coverage determinations:

  • The drug requires prior authorization
  • The Part D drug  is not on our formulary. This is a request for a "formulary exception."
  • A request for an exception to our plan’s utilization management tools - such as dosage limits or quantity limits. Requesting an exception to a utilization management tool is a type of formulary exception.
  • A request to cover a non-preferred Part D drug at the preferred cost-sharing level. This is a request for a "tiering exception."

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

How to request a coverage determination

You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination.  A member, their appointed representative or prescribing physician can submit a request for a coverage determination or exception request either orally or in writing by contacting Security Health Plan at:

Security Health Plan
1515 North Saint Joseph Avenue
P.O. Box 8000
Marshfield, WI 54449-8000
Fax: 715-221-9989

Providers or their agent(s) also may initiate requests for formulary exceptions or authorizations via:

  • Security Health Plan Pharmacy request line at 1-877-873-5611 or 715-221-9604 
  • Security Health Plan Pharmacy fax number at 715-221-9989 
  • Security Health Online (requires login with user name and password)

Standard prescription drug coverage determination process

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 the patient’s health condition requires. However, if the 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 provide our decision no later than 72 hours after we have received the physician's "supporting statement," which explains why the drug you are asking for is medically necessary.

We will provide the member a decision in writing about the prescription drug requested. We will fax the provider a decision about the prescription drug requested. If we do not approve the request, we must explain why, and provide appeal rights regarding our decision. If you have not received an answer from us within 72 hours after receiving the request, the request will automatically go to an independent organization for review.

Expedited prescription drug coverage determination process

A member, their appointed representative or prescribing physician can request an expedited coverage determination. An expedited request can be submitted orally or in writing to Security Health Plan. A request made or supported by a prescribing physician will be expedited if the physician indicates that applying the standard timeframe for making a determination might seriously jeopardize life, health or the ability of the patient to regain maximum function.

When Security Health Plan determines that a request qualifies for expedited handling, we will make our determination as expeditiously as the 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. The patient and the prescribing physician will be notified of the decision, whether favorable or adverse. If Security Health Plan first notifies you of a decision orally, we will also fax the provider about the prescription drug requested.  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 the right to file a redetermination (appeal).

To request an expedited coverage determination, you may call, fax or mail your written request to Security Health Plan at the numbers indicated above. If you write, the 24-hour review time will not begin until your request is received.

If Security Health Plan determines that the request is not time-sensitive and the patient’s health is not seriously jeopardized, Security Health Plan will notify you verbally and via fax, and will automatically begin processing your request under the standard reconsideration 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 CMS within 24 hours of the expiration of the adjudication timeframe and the IRE will issue a determination.