Coverage Determinations (Drug Coverage)
Some drugs may require a Prescription Drug Coverage Determination before your prescription can be filled by the pharmacy. Some drugs may not be on the formulary and other covered drugs may have requirements and limits. You can find a list of medications that require a coverage determination by viewing the Comprehensive Formulary (Standard, Enhanced or Prime).
You may ask Paramount to make an exception to the coverage rules. The types of exceptions you can request are:
- An exception for a prior authorization drug
- An exception for step therapy drug
- An exception on the quantity limit for a drug
- An exception for coverage of a non-formulary drug
- An exception for the tiered cost sharing drug
- An exception for a Medicare Part D excluded drug
Initiate Coverage Determination Request
Coverage Determinations may be initiated by telephone, fax, online submission, letter or email. To initiate a coverage determination or exception request you, your appointed representative or your prescriber may contact Paramount’s Prescription Drug Benefit Manager, CVS/Caremark in the following ways:
- Call 1-855-749-0851 to speak with CVS Caremark Customer Service Representative 24 hours a day, 7 days a week. TTY: 711
- Fax a request to 1-855-633-7673 Attention: CVS Caremark Part D Services Appeals and Exceptions
- Submit an online Coverage Determination Form directly from our website
- Send a written request to: CVS Caremark Part D Services Appeals and Exceptions, P.O. Box 52000 MC 109, Phoenix, AZ 85072-2000
- Email us at Paramount.MemberServices@ProMedica.org
Please refer to your Evidence of Coverage for a complete description of the guidelines that apply to the exceptions process.
Organization Determinations (Health Care/Medical Services-Non Urgent)
Some health care services require an organization determination prior to payment.
Please refer to your Evidence of Coverage for details.
Non-urgent determinations may take up to 2-14 calendar days. Your physician may request expedited handling (see below).
Both you and your requesting physician will be notified of the decision, whether favorable or adverse. If Paramount first notifies you of an adverse decision orally, we will mail written confirmation to you within 3 calendar days of the oral notification. 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 your right to file a re-determination (appeal).
How to Initiate an Organization Determination
To initiate an organization determination, you or your physician can complete any of the following:
- Mail prior authorization request to Paramount at P.O. Box 928, Toledo, OH 43697
- Fax prior authorization request to: Paramount’s Utilization Management staff at 419-887-2028 or toll free 866-214-2024
- E-mail prior authorization request to: Paramount’s Utilization Management staff at PHCReferralManagement@ProMedica.org
- Call Paramount’s Utilization/Case Management Department at: 419-887-2520 or toll-free 1-800-891-2520
- Providers may also submit high dollar Imaging procedures through the web-based prior authorization submission tool: McKesson Clear Coverage
- Note: Electronic or fax submission is preferred
Last updated: 09/30/2018