An initial determination is a decision made by the plan about a specific problem you have.
You need to request that an initial determination (decision) be made by the BlueCHiP for Medicare plan if you are having problems getting:
• The Part D prescription drugs you need
• Payment for a Part D drug you have already received
There are different types of determinations based on the type of service involved. If it is related to a Part D prescription drug problem, it is called a coverage determination.
These are some examples of issues you may have relative to your Part D prescription drug benefits that would require a coverage determination:
• You ask the Plan to pay for a prescription drug you have already received.
• You ask BlueCHiP for Medicare to pay you back for the cost of a drug you bought at an out-of-network pharmacy.
• You ask for a Part D drug that is not on the formulary. This is a request for a "formulary exception."
If you have an issue of this type, you, your doctor, or another provider may ask for an initial decision (in this case a coverage determination) on your behalf, or you can name
(appoint) someone to do it for you.
Last updated: 09/01/2015
Blue Cross & Blue Shield of Rhode Island is an HMO plan with a Medicare contract. Enrollment in Blue Cross & Blue Shield of Rhode Island depends on contract renewal.