If your pharmacy tells you that a prescription drug is not covered and you believe it should be covered, you can request a coverage determination (coverage decision). You can also request a coverage decision if there is a prior authorization restriction or quantity limit for a drug, or if you feel you are paying more than you should be.

To request a coverage decision, you can:

  1. Call Member Services;
  2. Write to us at: Prior Authorization Department, P.O. Box 25183, Santa Ana, CA 92799;
  3. Fax your request to us at 1-800-572-0531; or
  4. Log on to optumrx.com and submit a request. New users will be required to register.

Your doctor can request a coverage decision for you by:

  1. Calling Member Services.
  2. Writing us at: Prior Authorization Department, P.O. Box 25183, Santa Ana, CA 92799; or
  3. Faxing a request to us at 1-800-572-0531.

The Medicare Part D Coverage Determination Request Form is available for your use, however, it is not required.

Medicare Part D Coverage Determination Request Form – for use by members and providers. This is a CMS-model exception and prior authorization request form developed specifically for use by all Medicare Part D prescribing physicians or members.

A standard coverage determination request will be reviewed and a decision made within 72 hours of receiving your request or your prescribing doctor’s statement.

You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite the decision is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.

What happens if we deny your request?

If we deny your request, we will send you a written reply explaining the reasons for denial.You have the right to appeal if you are not satisfied with the initial decision. See the “Making an Appeal” section for more information. You can also click here to visit Medicare’s website for information on how to make an appeal.

For more information from Medicare on how to file a complaint, click here to go to Medicare.gov.

To request information for Aggregate Number of Grievances, Appeals and Exceptions to Grievances please call Member Services.