Coverage Determinations and Formulary Exceptions

Your benefits as a member of our plan includes coverage for Part D prescription drugs. When QHPNY makes a decision in regards to your drug benefits and drug coverage or about the amount we will pay for your drugs, it is called a Coverage Determination.


If you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower co-payment you have the right to ask us for an Exception. If you request an Exception, your physician must provide a statement to support your request.


You must contact us if you would like to request a Coverage Determination and/or a Formulary Exception. You cannot request an appeal if we have not issued a Coverage Determination. A full description of the Coverage Determinations and Exceptions process may be found in Chapter 9: Section 6 of your plan’s Evidence of Coverage document. Enrollees and physicians who have questions about or seeking status of a Coverage Determination or Exception should contact us using the below Customer Service phone numbers.


Requesting a Coverage Determination or Formulary Exception

To request a Coverage Determination or to file a Formulary Exception, you may:

 

 

QHP New York
Phone Fax Mail
Customer Service
Toll Free:
1-877-233-7058
TTD: 711
M-F, 8:00am - 8:00pm ET
1-877-817-0842  Quality Health Plans of New York
Pharmacy Department
2805 Veterans Memorial Highway
Suite 17
Ronkonkoma, NY 11779

Providers:  To view the CMS Medicare Part D Coverage Determinations and Exceptions Page, click HERE

Prior Authorization Forms

 

Medicare Prescription Drug Coverage Determination Form

Drug Specific Forms

 

Androderm or Androgel
Chantix
Cialis
Drugs to Avoid in the Elderly
Fentanyl
Immunosuppressive Therapy
Lidoderm
Lyrica
New Starts High Risk Medication
Oral Anti-Emetics
Rosiglitazone
Simvastatin
Topical Retinoids
Vancocin

Coverage Determination approval authorizations are typically approved until the end of the calendar year unless otherwise stated in the Prior Authorization criteria.

If you disagree with a coverage decision we have made, you can appeal our decision.