Coverage Determinations & 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:

Call to make an oral request – see contact information below

  • Fax or mail a written request – see the contact and mailing information below.
  • Click HERE to access the Request For Medicare Prescription Drug Coverage Determination Form
  • Click HERE to send a request via a SECURE electronic web message
  • PHONE Call Toll Free
  • 1-877-233-7058
  • Customer Service
  • TTY: 711
  • M-F, 8:00am to 5:00pm
  • FAX Toll Free Facimilie Service
  • 1-877-817-0842
  • Perfect for Fast-Track Requests
  • Secure and Confidential
  • ADDRESS Plan Home Office
  • Write or Visit
  • Quality Health Plans of New York
  • Pharmacy Department
  • 2805 Veterans Memorial Hwy, Suite 17
  • Ronkonkoma, NY 11779

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

Prior Authorization Forms

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.