Members Resources

Find tools, information, and other resources to help you get the most out of your benefits.

Part D Coverage Determination

What is a coverage determination?

A coverage determination is a decision made by LifeWorks Advantage (not the pharmacy) about your prescription drug benefits, including:

  • Whether a drug is covered
  • Whether you have met all the requirements for getting a requested drug
  • How much you’re required to pay for a drug, and
  • Whether to make an exception to a plan rule when you request it

A coverage determination may be requested for any of the following:

  • Covering a Part D drug for you that is not on the list of covered drugs (formulary).
  • If your health care provider or prescriber believes you need a drug that isn’t on the list of covered drugs (formulary).
  • If your network pharmacy can’t fill a prescription as written.
  • To remove a restriction for a covered drug.
  • If you or your prescriber believe that a coverage rule (such as prior authorization) should be waived.
  • Changing coverage of a drug to a lower cost-sharing tier. 
  • If you think you should pay less for a higher-tier drug because you or your prescriber believe you can’t take any of the lower-tier drugs for the same condition.
  • Request for payment.
What is an exception?

If a drug is not covered by LifeWorks Advantage, you can ask the plan to make an “exception.”

Coverage determinations include exception requests. You, the member, have the right to ask us for a utilization management exception if you believe you need a drug that is not on our formulary or should get a drug at a lower co-payment. If you request an exception, your doctor or other prescribers must give us a written statement that explains the medical reasons for requesting an exception.  Once we receive a statement from your doctor, we must make a coverage determination and notify you within 72 hours of receiving the request, or sooner if your health condition requires more immediate action. If immediate action is necessary, you or your physician can request that we review your situation within 24 hours. LifeWorks Advantage can accept or deny your request.

Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision. You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.

Examples may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.

Who can request a coverage determination / exception?

A coverage determination may be requested by any of the following:

  • You or your appointed representative may request a coverage determination.
  • Your prescribing physician or other prescriber may request a coverage determination for you on your behalf.
Where can a coverage determination / exception be filed?

To request a coverage determination, ask your provider or prescriber to visit this page.

How to request a Medicare Prescription Drug Coverage Determination, including an exception:

  • Call Provider Services at 844-854-6883 (TTY 711)
  • Submit the Medicare Prescription Drug Coverage Determination Form Online
  • Complete and mail or fax the 2021 Medicare Prescription Drug Coverage Determination Form
    • Fax: (855) 668-8552
    • Mail: LifeWorks Advantage PO Box 1039 Appleton, WI 54912-1039

How to request a Medicare Prescription Drug Appeal (Redetermination): 

Your prescribing physician or other prescriber may also request a coverage determination or exception by contacting the Pharmacy Help Desk at 1-866-270-3877 (TTY 711) 24 hours a day, and 7 days a week.

Lifeworks Advantage has 72 hours (for a standard request) or 24 hours for an expedited (fast) exception request from the date it gets your request to notify you of the decision.