What is a coverage determination?

September 20, 2009 by admin

A coverage determination is a Medicare drug plan's first decision about the services a member can receive as part of the plan's Medicare prescription drug coverage. This can include a decision whether or not to provide or pay for a drug, a decision about an exception request, a decision about a member's out-of-pocket costs (cost sharing) for a drug, or a decision about whether a member has met a prior authorization requirement for a requested drug.