Coverage Determination

A coverage determination is a decision we make about your benefits and coverage or about what we will pay for your prescription drugs. If your physician or pharmacist tells you that your prescription drug will not be covered, you or your physician should contact us and ask for a coverage determination.

Here are examples of coverage decisions you may ask us to make about your Part D drugs:

• You may ask us to make an exception, including:
  • Asking us to cover a Part D drug that is not on the plan’s Formulary.
  • Asking us to waive a restriction on the plan’s coverage for a drug (such as limits on the amount of the drug you can get).
  • Asking to pay a lower cost-sharing amount for a covered non-preferred drug.
• You may ask us whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on the plan’s Formulary but we require you to get approval from us before we will cover it for you.)
  • Please note: If your pharmacy tells you that your prescription cannot be filled as written, you will get a written notice explaining how to contact us to ask for a coverage decision.
• You may ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment.

If you disagree with a coverage decision we have made, you can appeal our decision.

You may use the following form to file a Part D coverage determination:

Coverage Determination Request Form

• You can call us at:

1-888-906-3889 (TTY: 711)

From October 1 – March 31, seven days a week, from 8am – 8pm and April 1 – September 30, Monday through Friday, from 8am – 8pm (you may leave a voicemail Saturday, Sunday and Holidays)

• Send a fax to:

1-866-235-5181

• Mail your request to:

Eon Health
Attn: Appeals & Grievances
3620 Enterprise Way
Miramar, FL 33025

Eon Health tracks and maintains records about the receipt and handling of grievances, appeals, and exceptions. We will also disclose grievances, appeals, and exceptions data to you upon request. Eon Health can also provide an aggregate number of grievances, appeals, and exceptions filed with our plans. To obtain this data, please call Eon Health at the following toll-free number:

1-888-906-3889 (TTY: 711)

From October 1 – March 31, seven days a week, from 8am – 8pm and April 1 – September 30, Monday through Friday, from 8am – 8pm (you may leave a voicemail Saturday, Sunday and Holidays)

Members may name a relative, friend, advocate, or someone else to act on his or her behalf. This process is called Appointing a Representative. Other persons may already be authorized under state law to act on a member’s behalf. In order to appoint another individual to act on a member’s behalf, both the member and the designated individual must sign and date a statement that gives this person legal permission to act as an Appointed Representative.

To appoint a representative, you may use this form: Appointment of Representative Form

After completing the form, please mail it to the following address:

Eon Health
Attn: Member Services
3620 Enterprise Way
Miramar, FL 33025

For questions regarding the process or status of a coverage determination, grievance, organization determination, redetermination, or reconsideration request, you or your appointed representative should call Eon Health at the following toll-free number:

1-888-906-3889 (TTY: 711)

From October 1 – March 31, seven days a week, from 8am – 8pm and April 1 – September 30, Monday through Friday, from 8am – 8pm (you may leave a voicemail Saturday, Sunday and Holidays)