Pharmacy Transition Process
When taking a medication that is no longer covered by the plan, Nascentia Health Plus wants to ensure your prescription drug transitions are safe and as easy to navigate. Please review the information below for guidance on any prescription drug transition.
Pharmacy Exceptions and Coverage Determinations
If you require a medication that is not on Nascentia Health Plus’ formulary and you cannot use a formulary alternative, or if you require an exception to one of our utilization management rules, you have the right to request a coverage determination. Review the information below to learn more.
Coverage Determination Form (pdf)
You may also initiate a coverage determination by contacting Envision Rx:
- Call 1.833.459.4424 (TTY 711), 24 hours a day, 7 days a week
- Visit https://envision.promptpa.com
Pharmacy Appeals and Grievances
Is Your Drug Covered By Our Plan?
If a drug you take isn’t covered by our plan and you can’t switch to another drug, you and your prescriber can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your prescriber says that you have medical reasons that justify asking us for an exception, your prescriber can help you request an exception to the rule. This is called a “coverage determination.”
You and your prescriber can complete the Coverage Determination Request Form (pdf) and submit it to the pharmacy department for consideration.
If we approve your request for a Formulary exception, our approval usually is valid until the end of the plan year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.
If we deny your request for a Formulary exception, you can ask for a review of our decision by making an appeal. This is called a “redetermination.”
You and your prescriber can complete the Redetermination Request Form (pdf) and submit it to the Nascentia Health Plus appeals department for consideration.
If your request is denied, you have the right to ask for an independent review of the plan’s decision. You have 60 days from the date of the plan’s Redetermination Notice to ask for an independent review. You can complete the Request for Reconsideration Form (pdf) and submit it to the plan for action.