Forms and Information

Coverage Determination

Quality Assurance

Coverage Determination

What is a coverage determination?

A coverage determination is a decision Magellan Rx Medicare makes about a member's benefits and coverage or about the amount we will pay for a member's prescription drugs. If we decide that a certain prescription drug is not covered, a coverage determination may be requested by the member, or on behalf of the member by the member's authorized representative, provider or prescriber.

Coverage determination forms can be found below:

• Coverage Determination Form
• Hospice Coverage Determination Form

If the member disagrees with the plan’s coverage determination, an appeal may be filed.

Who may file an appeal of the plan's coverage determination?

When filing an appeal of a coverage determination about a Medicare Part D drug, the member, the member's authorized representative, provider or prescriber may file a standard appeal request (7 day response time) or a fast appeal request (72 hour response time).

The appeal form can be found below:

• Coverage Redetermination Form

A coverage determination request or an appeal can be filed by mail, fax or phone per the information below:

Magellan Rx Medicare
P.O. Box 1433
Maryland Heights, MO 63043
Phone:1-800-424-5870 (TTY 711)
Fax: 1-800-424-5872

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Quality Assurance

Magellan Rx Medicare has established quality assurance measures and systems to reduce medication errors, adverse drug interactions and improve medication use for all of our members. These reviews are especially important for members who have more than one doctor who prescribe their medications, use more than one drug, or have more than one pharmacy.

Utilization Management

Magellan Rx Medicare utilization management tools encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits and step therapy.

Drug Utilization Review

We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one provider or prescriber who prescribes their drugs.

We do a review each time a member fills a prescription. We also review our records on a regular basis. During these reviews, we look for potential problems such as:

• Drugs that may not be necessary because the member is taking another drug to treat the same medical condition
• Drugs that may not be safe or appropriate because of the member's age or gender
• Certain combinations of drugs that could harm the member if taken at the same time
• Prescriptions written for drugs that have ingredients the member is allergic to
• Possible errors in the amount (dosage) of a drug the member is taking

If we see a possible problem in a member's use of medications, we will work with the provider or prescriber to correct the problem.

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