Coverage determination requests are available for providers to request the following exceptions to Medica Part D Formulary and medication coverage issues:
- Non-formulary exceptions
- Exception to a QL requirement
- Exception to a ST requirement
- Complete a PA requirement
- Formulary Tier Placement Exception (Open formulary only)
Download the Coverage Determination forms.
Fax completed forms to MedImpact at 1-858-790-7100.
Medica will complete the review of all standard coverage determination review requests within 72 hours (including weekends and holidays). Providers will receive a faxed notification of the result of the review immediately upon completion of the coverage determination review. Members will be mailed a copy of the results of the review.
Medica will complete the review of all urgent or expedited requests within 24 hours (including nights and weekends). Providers will receive a faxed notification of the result of the coverage determination review. Members will be notified by telephone if the urgent coverage determination request has been denied and a copy of the review results will be mailed.
Coverage determination denial letters include the rights of an appeal. All appeals should be sent to Medica Clinical Appeals.
View contact information.
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