Commonwealth Community Care

One Care

Pharmacy Program » Exceptions, Appeals & Grievances

Exceptions, Appeals & Grievances

Your Part D Prescription Drugs: Coverage Decisions, Exceptions
& Appeals

What is a coverage determination?

A coverage determination is a decision Commonwealth Care Alliance makes about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. Coverage determinations are also called coverage decisions.

What is an exception?

If a drug is not covered in the way you would like it to be covered, you can ask us to make an “exception.” An exception is a type of coverage determination. Similar to other types of coverage determinations, if we turn down your request for an exception, you can appeal our decision. When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request.

Asking for a coverage determination or exception

You, your physician, or your appointed representative may file a coverage determination, including an exception, by:

Telephone: 1-866-610-2273

Fax: 1-855-668-8552

Mail: Navitus Health Solutions
P.O. Box 1039
Appleton, WI 54912-1039

Related Forms

  • Download the Model Drug Coverage Determination Form (pdf)
  • Download the Request for Redetermination of Medicare Prescription Drug Denial Form (pdf)


To view the PDF files above, you may need to download a free copy of Adobe® Acrobat Reader software on your computer. (This link takes you away from the Commonwealth Care Alliance website pages.) Click here for more information about Adobe Acrobat.

*When you click this link, you will leave Commonwealth Care Alliance’s website.

Last Updated 06/18/2014