Initial Drug Coverage Determinations

The enrollee, the enrollee’s appointed representative ( “Instructions on Appointing a Representative” for details), or an enrollee’s prescribing physician may request a standard coverage determination by mailing a signed written request or the enrollee may call the Member Services Department to make an oral appeal.  The enrollee may call toll, Monday through Friday, to 1-800-401-2740.  Enrollee’s needing TTY/TDD services should call 1-800-955-8771. 

Freedom Health will notify the enrollee (and the prescribing physician involved) of its determination as expeditiously as the enrollee’s health condition requires, but no later than 72 hours after the date and time Freedom Health receives the request for a standard coverage determination.  In the case of a request for an expedited (fast) coverage determination, Freedom Health will notify the enrollee and the physician involved of its decision as expeditiously as the enrollee’s health condition requires, but no later than 24 hours after receiving the request. 

Exceptions Process

The enrollee may ask for two types of exceptions:  (1) tiered co-payment structure or (2) formulary.  Once the exception is granted, it will continue to be in force only for the calendar year.

Exception #1:  In the case of a request for a tiered co-payment exception, the request will not be processed until the enrollee’s prescribing physician provides a supporting statement orally or in writing.  Freedom Health requires physicians who provide oral statements to subsequently provide a written supporting statement.  Freedom Health will provide the prescribing physician 96 hours following receipt of the standard request or 48 hours after receiving an expedited (fast) request before issuing its determination.  The supporting statement must indicate that the preferred drug for the treatment of the enrollee’s condition:  (1) would not be as effective as the requested drug and/or (2) would have adverse effects.  Receipt of a physician’s supporting statement does not necessarily result in an automatic favorable determination.

Freedom Health will provide coverage at the cost-sharing (co-payment) level that applies for preferred drugs not at the generic cost-sharing level.

Exception #2:  The formulary exception process will be instituted when an enrollee argues that the utilization management requirement should not apply to  his/her situation due to one of the following factors: 

The requested drug is medically required and other on-formulary drugs and dosage limits will not be effective because of one of the following three reasons:

  1. All covered Part D drugs on any tier of the Freedom Health formulary would not be as effective for the enrollee as the non-formulary drug and/or would have adverse effects.
  2. The number of doses available under a dose restriction for the prescription drug (a) has been ineffective in the treatment of the enrollee’s disease or medical condition or (b) based on both sound clinical evidence and medical and scientific evidence, the known relevant physical or mental characteristics of the enrollee, and known characteristics of the drug regimen, is likely to be ineffective or adversely affect the drug’s effectiveness or patient compliance.
  3. The prescription drug alternative(s) listed on the formulary or required to be used in accordance with step therapy requirements:  (a) has been ineffective in the treatment of the enrollee’s disease or medical condition or, based on both sound clinical evidence and medical and scientific evidence, the known relevant physical or mental characteristics of the enrollee, and known characteristics of the drug regimen, is likely to be ineffective or adversely affect the drug’s effectiveness or patient compliance or (b) has caused or, based on sound clinical evidence and medical and scientific evidence, is likely to cause an adverse reaction or other harm to the enrollee.

Freedom Health will grant the formulary exception when it determinations that one of the above three factors has been demonstrated, and the drug would be covered but for the fact that it is an off-formulary drug.  Freedom Health will determine the level of cost sharing (co-payment) that will apply for non-formulary drugs approved under the above exceptions process. 

Freedom Health will not begin the formulary exception review process until the enrollee’s prescribing physician provides a supporting statement demonstrating that one of these three factors exists.  As in the exception for a tiered co-payment, Freedom Health will provide the prescribing physicians up to 96 hours following receipt of the standard request or 48 hours after receiving an expedited (fast) request before issuing its determination.

For more details on the formal Freedom Health coverage determination process and the remainder of the appeals options, please click the link below for the current Explanation of Coverage.  The grievance process for Part D benefits can be found in Section 12.


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