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Prescription Drugs

Coverage Determinations

Coverage determination is the process by which Jefferson Health Plans decides whether a Part D drug prescribed for you is covered. It also decides the amount, if any, you are required to pay. An initial coverage decision about your Part D drugs is called a coverage determination.

About Coverage Determinations

You can ask Jefferson Health Plans for a coverage determination if the following apply:

  • You need a drug that we don’t cover or need us to waive a rule or restriction we have on a drug in our formulary. Learn more about exceptions.
  • You want us to cover a drug on our formulary and you believe you meet any rules or restrictions we have for this drug.
  • You want us to pay you back for a drug you already got and paid for.

You, your prescriber or an authorized representative can make a request for a coverage determination or exception, and for exceptions, we also need a statement from your prescriber supporting your request.

Making a Request

  • By Phone

    Call us at 1-866-901-8000 (TTY 1-877-454-8477) or fax 1-866-371-3239.

Additional Resources

CMS Request for Coverage Determination

View Form

Member Reimbursement Form

View Form

Prior Authorizations

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Hospice Determination Form

View PDF