Prescription Drug Coverage Determination Request (Prior Authorization)
If there is a restriction for a drug, it usually means that the member or the provider will have to take extra steps in order for us to cover the drug. If you want us to waive the restriction for the member, a coverage determination is required.
Who can ask to initiate a coverage determination?
The member or provider can ask the plan to make an exception coverage of the drug when they feel we should cover a medication without having restrictions apply. If your provider says that the member has medical reasons that justify asking us for an exception, the provider can help request an exception to the rule.
How can a coverage determination be requested?
The member and/or the doctor can make the request for a coverage determination by contacting Envision Rx. A coverage determination may be requested either:
- Orally by calling 1-855-408-0010 (TTY: 711); OR
- Electronically by visiting our website PromptPA; OR
- Written by downloading the Request Coverage Determination (Part D) form and then either faxing 1-866-250-5178 or mailing to:
Attn: Coverage Determinations Dept.
2181 East Aurora Road
Twinsburg, OH 44087
NOTE: When using PromptPA:
Virginia Premier Elite members will need to add ‘*VPE’ to their member ID number. For example: 1234567*VPE
How long will I get a decision about my Coverage Determination?
Once we receive a written statement with the medical reasons for the exception request from a provider, we must notify the provider and member with our decision no later than 24 hours for an expedited request or 72 hours for a standard request. The notification will be made by telephone, in addition the member and the provider will receive a written notice of the decision.
A request may be expedited if we determine, or the provider informs us, that your life, health, or ability to regain maximum function may be seriously jeopardized by waiting for a standard request.
What if the coverage determination was denied?
If the request is denied, the member has the right to appeal by asking for a review of our decision. The doctor or the member must request this appeal within 60 calendar days from the date of our decision. The member or provider may request the appeal to be standard or expedited. Once we receive the physician’s statement, we must notify the member of our decision no later than 72 hours for an expedited request (7 days for a standard). An appeal can be requested either:
- Orally by calling 1-800-727-7536 extension 66728 (TTY: 711); OR
- Electronically by visiting our Complaints, Appeals and Grievances Page; OR
- Written by either faxing 1-804-649-9647 or mailing to:
Attn: Grievance & Appeals
PO Box 5244
Richmond, VA 23220