A coverage determination is any determination (i.e. an approval or denial) made by Champion Health Plan regarding your Medicare Part D prescription drug coverage. Your requests for Part D coverage determination may include:
Asking whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on the Plan’s List of Covered Drugs (Formulary) but requires our approval before it is covered.)
Asking us to pay for a prescription drug you already bought.
Asking us for an exception. (If a drug is not covered in the way you would like it to be covered, you can ask the Plan to make an “exception.”)
Examples include:
When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. Your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception.
You (or your representative or your doctor or other prescriber) may use the form below to submit your request for a Part D Coverage Determination:
Medicare Prescription Drug Determination Request Form
Download the Coverage Determination Request Form
Please note: If you do not use this form, you will need to provide us the same information indicated in the form so we can process your request in a timely manner. The form cannot be used to request Medicare non-covered drugs, including fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).
Once the form is completed, submit it to MedImpact Healthcare Systems, Inc. at the contact information located below.
To start your Part D Coverage Determination Request, please contact or submit your form to:
MedImpact – Prior Authorization Department
Call: 844-282-5341
Fax: 858-790-7100
Hours of Operation: PA staff is available 6:00am – 6:00pm Monday – Friday (PST) and 6:00am-2:30pm PST on weekends
Mailing Address: 10181 Scripps Gateway Court, San Diego, CA 92131
Website: www.medimpact.com
If you need additional assistance on Part D Prescribed Drug benefits, you may call Champion Health Plan of California, Inc. or Renal Payer Solutions, Inc. Pharmacy Services Department at 1-800-885-8000 | TTY 711, 8:00 a.m. to 8:00 p.m., 7 days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30. Calls to this number are free. Member Services also has free language interpreter services available for non-English speakers. TTY requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
As a new member to Champion Health Plan, you may be taking prescription drugs that are not on our Part D Formulary (drug list) or that are on the formulary but require prior authorization, step therapy, or are subject to quantity limits. When this occurs, you are eligible for a transition supply of the drug (see below for details).,
If you are a continuing member, and are currently taking drugs that have changes or the drug has new use restrictions from one year to the next (negative changes), you may also be eligible for a transition supply of the drug.
During your first 90 days of membership in our plan, we will provide a temporary transition supply of a Part D eligible drug when:
For prescriptions filled at a retail or mail-order pharmacy, we will provide a temporary supply of up to 30 days (or fewer if the prescription is written for fewer days). If your prescription is written for fewer than 30 days, we will allow multiple fills to provide up to 30 days of medication. Refills for the transition supply are permitted during the 90-day transition period.
For members who are residents of a long-term care (LTC) facility, we will provide a temporary supply of up to a 31-day supply (unless the prescription is written for fewer days), with multiple fills permitted during the first 90 days of enrollment to provide up to a total of 91 days of medication, consistent with dispensing increment requirements.
Please speak with your prescribing doctor to determine whether an appropriate alternative drug is available on our formulary. If no appropriate alternative is available, you or your prescriber may request a formulary exception to ask the Plan to cover the drug or waive the applicable utilization management requirement.
If you are a resident of a long-term care facility, we may cover at least a 91-day and up to a 98-day transition supply, depending on the dispensing increment, during the first 90 days of coverage. After the first 90 days, we may also provide a 31-day emergency supply unless you have a prescription written for fewer days.
If you are a member with a level of care change, we may cover a 31-day transition supply if you are moving from home, or a hospital stay to a long-term care facility. We may cover a 30-day transition supply if you are moving from a long-term care facility, or a hospital stay to home.
If you have any questions about our transition policy or need help asking for a formulary exception, please call Champion Health Plan of California, Inc. or Renal Payer Solutions, Inc. at the contact listed below.
Member Services Department at 1-800-885-8000 | TTY 711, 8:00 a.m. to 8:00 p.m., 7 days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30. Calls to this number are free. Member Services also has free language interpreter services available for non-English speakers. TTY requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
*Form to file an Appeal for Part D Prescription Drugs is list below.
