Part D Coverage Determination and Appeal Requests

Asking for Prescription Drugs to be Covered

You can fill out this request form (see below) to begin the process, your physician will need to fill out the Part D Coverage Determination form, which you can download and print by clicking the following link:
Medicare Prescription Drug Coverage Provider Communication Form

Standard requests have a 72-hour timeframe to resolve the request, which begins once the prescribing physician or prescriber provides supporting documentation.

Expedited requests have a 24-hour timeframe to resolve the request, which begins once the prescribing physician or prescriber provides supporting documentation.

Coverage Determinations—You or your physician requests a drug from FirstCare Advantage Dual SNP, such as a drug that is not on the formulary. FirstCare Advantage Dual SNP (HMO SNP) works with its Pharmacy Benefits Manager, Navitus Health Solutions to review Coverage Determinations. Your request will reviewed and a coverage decision will be provided to you and your physician. You may ask for an expedited coverage decision if you feel you need a fast decision.

Appeals—if we deny coverage or payment for a prescription that you think we should cover or pay for, you may request an appeal. You can ask us to “expedite” or give you a quick decision if we have denied coverage (but not if your appeal is related to payment for services you already received). Medicare Part D Coverage Determination and Appeal Request Form.

H5742_WEBSITE_2020_A | Last updated: 10/01/19.

Resources

Access a Doctor, 24/7/365

FirstCare Virtual Care—powered by MDLIVE lets you connect with a doctor from wherever you are. For more details, click here.

Talk to a Nurse—Nurse24™

Need care advice? Should you see a doctor? Get the info you need today! FirstCare members can talk to a nurse 24/7 by calling 1-855-828-1013 to get answers 24 hours a day, 7 days a week! TTY users can call 7-1-1 or 1-800-955-8771. Voice communication is available at 1-800-955-8770.

Utilization Management

Ever wonder how we decide what services to authorize? Our utilization management (UM) decisions are based on medical evidence and consensus of health care professionals. For more details, click here.

How to Learn More

Schedule a sit-down:
Feel free to contact us, and a FirstCare Advantage Dual SNP (HMO SNP) representative will gladly sit down with you and compare the plans in greater detail.

Call us at:
1-866-229-4969
We are available;
October 1- March 31, 8 a.m. to 8 p.m. Central Time (CT) daily;
April 1- September 30, 8 a.m. to 8 p.m. Central Time (CT) Monday through Friday.

For TTY or for accommodation of persons with special needs, please call TTY 7-1-1.

Or, write:
FirstCare Advantage Dual SNP (HMO SNP)
Attn: Customer Service
1901 West Loop 289, Suite 9
Lubbock, TX 79407

"What's Covered" App
Centers for Medicare & Medicaid Services (CMS) has an app that gives you access to content about original Medicare. For more information, click here.

Medicare D-SNP
FirstCare Advantage Dual SNP (HMO SNP)