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