Information on Coverage Determinations, Prior Authorization, Exceptions, Step Therapy Requirements and Redeterminations (Appeals).
HIP has created an exceptions and appeals resource for the web site to provide individuals with the instructions and the forms they might need for Medicare Prescription Drug exceptions and appeals in one, convenient location. On this page, you will find instructions for the following items: Coverage Determinations, Prior Authorization, Exceptions, Step Therapy Requirements and Redetermination (Appeals). Formulary Exceptions, Prior Authorization and Step Therapy requests are only applicable to certain medications. If your medication does not appear on the formulary, you may ask for a formulary exception. To find out if Prior Authorization and Step Therapy apply to your medication, please look up your medication on the Medicare formulary search tool and click "Show Notes". If any of these requirements apply to your medication, you will find additional instructions and required forms in this section.
You may read more about these items in your Evidence of Coverage (Contract), which is also posted on this site.
| Category | Definitions / Instructions: | Form should be sent to | Click here for form (as applicable) |
| Coverage Determinations | Initial coverage determination means the Plan's decision as to whether to provide or pay for a Part D drug including determinations on medical necessity, drugs not on the formulary, drugs furnished by an out-of-network pharmacy, drugs that are benefit exclusions, drugs requested as exceptions, and decisions on cost-sharing amounts. You may a contact HIP Customer Service Advocate concerning your prescriptions or any questions you may have or alternatively, utilized the form provided on the HIP web site for a Prescription Drug Coverage Determination. | Please send your HIP Medicare Prescription Drug Coverage Determination form to: FAX: 646 - 447- 3061 or to HIP Pharmacy Services / Clinical Review, PO Box #1520; JAF Station, New York, NY 10001. | See Coverage Determination form |
| Prior Authorization | HIP may require a prior authorization for certain medications. This means that your doctor will need to obtain an approval from HIP before you fill your prescriptions. If your physician does not get prior approval, HIP may not cover the drug.
If you have a situation where your medication is lost or stolen, you may request a prior authorization to address the situation. | Please call HIP Customer Service at 1-800-447-8255 between the hours of 8:00 am to 8:00 pm. | Not Applicable |
| Formulary Exceptions | If your medication is not included in this formulary, you should contact HIP Customer Service and ask if your medication is covered by your benefit. If you learn that HIP does not cover your drug, you have two options:
| Please call HIP Customer Service at 1-800-447-8255 between the hours of 8:00 am to 8:00 pm. | Please use Medicare Formulary Search tool to see if your medication is on the formulary. |
| Step Therapy Requirements | Step Therapy Requirements are Protocols where in some cases, HIP will require you to first try certain medications to treat your medical condition before HIP will cover another drug. For example, Drug A and Drug B both treat your medical condition. HIP may not cover Drug B unless you try Drug A first. If Drug A does not work for you, HIP will then cover Drug B. | Your Physician must send the Certificate of Medical Necessity form to: FAX: 646 - 447- 3061 or to HIP Pharmacy Services / Clinical Review, PO Box #1520; JAF Station, New York, NY 10001. | Please use Medicare Formulary Search tool to see if applicable to your medication |
| Redetermination (Appeals) | If you have requested one of the above items and your request was not granted, you may appeal this item by following the instructions in your denial letter (either by writing a letter or by using the attached form). | For an Expedited Appeal:
For a Standard Appeal:
Walk-in: HIP Customer Service Member Access Unit 55 Water Street New York, NY 10041 | See Redetermination form. |
H3330_H07_086 9/07
S5741_S07_026 9/07
