Coverage Determinations and Exceptions
What is a coverage determination?
A coverage determination is a decision Absolute Total Care 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 authorized representative may file for a coverage determination, including an exception by contacting Absolute Total Care. See contact information below.
- Phone: 1-844-202-6824 (TTY: 711)
- Fax: 1-877-941-0480
Please see below for the Medicare Prescription Drug Coverage Determination Request Form. (Please note: You cannot use this form for Medicare non-covered drugs: fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over the counter drugs, or prescription vitamins - except prenatal vitamins and fluoride preparations.)
If Absolute Total Care denied your request for coverage of a prescription drug or payment of a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination.
This form may be sent to us by mail or fax:
- Phone: 1-877-861-6724
- Fax: 1-844-273-2671
Absolute Total Care (Medicare-Medicaid Plan)
Attn: Appeals and Grievances — Medicare Operations
7700 Forsyth Blvd
St. Louis, MO 63105
If you have any questions, call Member Services at 1-855-735-4398. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711.