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What are some of the restrictions to drug coverage?
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Some drugs may have additional requirements or limits on coverage. These requirements and limits may include:
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Prior Authorization: Some drugs require that you to get prior authorization or approval from us before the pharmacy will fill your prescriptions.
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Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover.
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Step Therapy: In some cases, we may require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example: if Drug A and Drug B both treat your medical condition, we may not cover drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
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Complaints and Grievances
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If you are a member or provider and you have a complaint or grievance about your prescription benefit, you can write us at:
Physicians Health Choice
Attn: Grievance Department
P.O. Box 29429
San Antonio, Texas 78229-9998
or call us at 1-866-550-4736 or fax to 1-866-331-4362.
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Coverage Determination and Exceptions
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Should you have any difficulty getting your drugs at the pharmacy, or you are not satisfied with a decision we made about your drugs: you have several options.
First: You can ask for an Exception:
You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
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You can ask us to waive coverage restrictions or limits on your drug.
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Formulary Exception: You can ask us to cover your drug even if it is not on the formulary.
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Tiering Exception: You can ask us to provide a higher level of coverage for your drug. For example: if your drug is usually considered a Specialty Drug, you can ask us to cover it as a Preferred Generic instead. This would lower the amount you would have to pay for your drug. Please note, if we grant your request to cover a drug that is not on our Formulary (our approved list of drugs), you may not ask us to provide a higher level of coverage for the drug.
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To ask for an exception or for more information, contact Envision at 1-866-417-3071. Providers wanting to supply a supporting statement to Envision may call 1-866-417-3071. Calling is the quickest and most efficient way to request an exception. However, if you prefer, you have the option to submit the following document to Envision.
Coverage Determination(PDF)
Fax to 1-866-205-5178 or
Mail To:
Envision Pharmaceutical Services, Inc.
2181 East Aurora Road, Suite 201
Twinsburg, OH 44087
Second: You can Appeal our decision:
Once you have received the denial letter, you can challenge our decision not to cover your drug. You must do this within 60 calendar days of being denied, and your request must be in writing.
Please mail your request for an appeal to:
Physicians Health Choice
Attn: Appeals P.O. Box 29429
San Antonio, Texas 78229-9998
or call Physicians Health Choice at 1-877-299-7213 or fax to 1-866-322-7276.
For more information about the levels of appeal, please refer to your Evidence of Coverage or call Physicians Health Choice at 1-877-299-7213 or fax to 1-866-322-7276. For more information about your rights, please call 1-800-MEDICARE. You can learn more by reviewing the Medicare Prescription Rights.
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Who
can Appeal an adverse decision?
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Any Physicians Health Choice Member or their appointed representative can appeal an adverse decision. In order for an appointed representative to appeal on the Member’s behalf- the representative must be an authorized representative (must have the appropriate power of attorney) and must have completed and provided to us the approved Medicare form.
Send completed and signed form to:
Physicians Health Choice
P.O. Box 29429
San Antonio, TX 78229-9998.
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