Coverage Determinations & Exceptions

When PUP makes a decision whether or not to provide or pay for a Part D drug, it’s called a Coverage Determination.

There are “exceptions” for some Coverage Determination decisions, including:

  • A “formulary exception” – When you believe you need a drug that is not on our formulary
  • A “tiering exception” – When you believe you should get your drug at a lower cost share

All exception requests must be supported by a statement by the prescribing physician. Standard Coverage Determinations will be made 72 hours. Fast Coverage Determinations will be made within 24 hours.

How to request a Coverage Determination

  • CALL: 1-888-980-8764 (TTY 1-800-498-5428)
  • FAX: 1-800-527-0531 (for standard appeal)
  • WRITE: Prior Authorization Dept
    3515 Harbor Blvd
    Costa Mesa, CA 92626
  • Physicians can call 1-800-711-4555 for standard or expedited coverage

You, your appointed representative, or your provider may request a Coverage Determination or exception by completing the Request for Medicare Part D Coverage Determination Form. Please choose from the links below.

How to Appoint a Representative

An appointed representative is a relative, friend, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal. If you would like to appoint a representative please complete the following CMS Appointment of Representation form (Form CMS-1696). You and your appointed representative must complete this form and send it to us with your request or grievance.

How to File an Exception

You or your doctor may ask us to do the following:

  • Cover your Part D drug even if it isn’t on our Formulary
  • Waive coverage restrictions or limits on your Part D drug, such as a quantity limit
  • Provide a higher level of coverage for your Part D drug
  • Cover the Part D drug at the cost-sharing amount for a drug in a different tier

Please note: You may not ask to do the following:

  • To provide a higher level of coverage for the drug if we grant your request to cover a drug that is not on our formulary.
  • To provide a higher level of coverage for Part D drugs that are in the Specialty Drug tier.

The supporting medical information from your doctor should be sent to us with the exception request.

If approved, your exception request is valid for the rest of the plan year, as long as your doctor continues to prescribe you the Part D drug and it continues to be a safe way to treat your condition.

If we approve your exception request for a Part D non-formulary drug, you cannot request an exception to the copayment or coinsurance amount we require you to pay for the drug.