Coverage Determination

A Coverage Determination Request is a Prescription Part D Drug Coverage decision made by Healthy Mississippi. Different Part D Coverage determinations you can request include:

• Whether a drug is covered for you and whether you satisfy any coverage rules. (Typically, when your drug requires our approval before it is covered despite being on the Plan's List of Covered Drugs.)
• Reimbursement for a prescription drug you already bought.
• A Formulary exception. (If a drug is not covered in the way you would like it to be covered, you can ask the Plan to make an "exception.") Examples include:
  • Asking for coverage of a drug that is not on the drug list
  • Asking to pay a lower cost-sharing amount for a covered non-preferred drug
  • Asking us to remove the extra rules and restrictions on the Plan's coverage for a drug such as:
    • Being required to use the generic version of a drug instead of the brand name drug
    • Getting plan approval in advance before we will agree to cover a drug for you
    • Quantity Limits

To find out more about the Part D Coverage Redetermination Process, please refer to your Evidence of Coverage (EOC) or call a Member Services.