Formulary Exceptions and Coverage Determinations

If a drug is not covered in the way you would like it to be covered, you can ask the plan to make an “exception” by submitting a formulary exception form, called a Coverage Determination Request Form.  An exception is a type of coverage decision.  Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

To print the Centers for Medicare and Medicaid Services (CMS) Coverage Determination Request form, click here (clicking on this link will take you away from UPHP’s website).

To print the UPHP Medicare Part D Coverage Determination Request Form, click here.

The doctor’s office may submit either form via fax to Magellan Rx at 248-341-8133 or via mail to:

Magellan Rx Management
PO Box 2187
Maryland Heights, MO 63043

Click here for a more detailed description of the Medicare Prescription Drug Coverage Determination and Exceptions process.

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Page Last Updated: 03/19/2019