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Coverage Decisions

It’s possible there could be a prescription drug you’re currently taking, or one that you and your provider think you should be taking, that isn’t on our drug list or is on our drug list with restrictions. There are things you, your representative*, or your provider can do if your drug isn’t covered in the way that you’d like it to be covered.
If there’s a restriction on the drug, you, your representative*, or your provider can ask for a coverage determination.

The request can be submitted by:

  • Phone: You can call Member Services at 1-713-442-CARE (2273) or 1-866-535-8343 and request for a coverage determination.
  • Mail or Fax: You can download our Coverage Determination Form and send to our Prior Authorization department via fax (1-844-541-8508 or 713-442-4848) or mail (KelseyCare Advantage, Attn: Pharmacy Services, PO Box 841569, Pearland, TX 77584)
  • Web: You can use our form to submit a coverage determination request online.

*Please note, that in order for your appointed representative to initiate a coverage decision for you, a valid and up-to- date Appointment of Representative (AOR) Form must be on file. If you are unsure about the status of your representative or would like to complete an AOR form, you can call Member Services at 1-713-442-CARE (2273) or 1-866-535-8343 to request an AOR form by mail or download an AOR form and fax (1-844-541-8508 or 713-442-4848) or mail (KelseyCare Advantage, Attn: Pharmacy Services, PO Box 841569, Pearland, TX 77584).

If you disagree with a decision made on a previous coverage decision, you, your representative*, or your provider can ask for an appeal.

The request can be submitted by:

  • Phone: You can ask our Appeals & Grievances department and request for an appeal (1-866-535-8343, TTY 711)
  • Mail or Fax: You can download our Coverage Determination Appeals Form and send to our Appeals & Grievances department via fax 713-442-9536 or mail (KelseyCare Advantage, Attn: Grievance and Appeals, P.O. Box 841569, Pearland, TX 77584-9832).
  • Web: You can use our form to submit a coverage determination online.
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