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HMSA Medicare Advantage Coverage Determination Request

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A coverage determination or coverage decision is HMSA’s initial decision about whether we’ll provide coverage for a Part D prescription drug, allow an exception request, or lower a drug tier.

You, your prescriber, or your authorized representative can ask us to make a coverage determination verbally or in writing. If your health requires a quick response, you must ask us to make a “fast coverage decision.” A “fast coverage decision” is also called an “expedited coverage determination.” When we give you our decision, we’ll use the “standard” deadlines unless we’ve agreed to use the “fast” deadlines. A standard coverage decision means we’ll give you an answer within 72 hours after we receive your doctor’s statement. A fast decision means we’ll answer within 24 hours.

Instructions

To request a coverage determination or for more information about the process or status of a request, contact HMSA’s pharmacy benefit manager.

Mail the completed form to:
Medicare Coverage Determinations and Appeals
P.O. Box 52000 MC109
Phoenix, AZ 85072-2000

  • Fill out your name, date of birth, address, phone number, and HMSA Subscriber ID number.
    • If you’re making the request on someone else’s behalf, include your name as the Requestor, your relationship to the enrollee, address, and phone number.
  • List the name of the drug you’re requesting a coverage decision for.
  • Choose the type of coverage determination request.
  • If this is a request for a “fast decision,” check the box marked “I need an expedited coverage determination."
  • Sign the form.
  • Fill out your physician’s name and contact information. (For requests that require supporting documentation, HMSA will contact your prescriber to get required information.)

In addition to mail, you can also submit your request by phone or fax.

Call
1-855-479-3659

TTY 711

These toll-free numbers are available 24 hours a day, seven days a week.

Fax
1-855-633-7673, or after business hours, call the toll-free numbers above.

Your physician or your pharmacist can also request a coverage determination on your behalf using the same form and submission methods above. Prescribers need to provide supporting information:

  • Diagnosis and Medical Information
  • Rationale for Request
  • Our pharmacy benefit manager provides services and manages HMSA’s drug formulary for HMSA’s commercial, Medicare, and QUEST programs.
CURRENT AS OF 10/01/2024