Get REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION (EBS). Prescription Drug Coverage

What's a "Local Coverage Determination" (LCD)? LCDs are decisions made by a Medicare Administrative Contractor (MAC) whether to cover a particular item or service in a MAC's jurisdiction (region) in ance with section 1862(a)(1)(A) of the Social Security Act.

Asking your health plan for a benefit or for them to cover a service is called an Organization Determination request. It may also be called a Prior Authorization request.

National Coverage Determinations (NCDs) are developed by the Centers for Medicare and Medicaid Services (CMS) and applied on a nationwide basis. NCDs generally describe the criteria and coverage limitations that apply to particular services, procedures or devices for coverage and payment purposes.

A national coverage determination (NCD) is a United States nationwide determination of whether Medicare will pay for an item or service. It is a form of utilization management and forms a medical guideline on treatment.

The following are examples of when you can ask us for a Coverage Determination: If there is a limit on the quantity (or dose) of a drug and you disagree with the limit. If there is a requirement that you try another drug before we will pay for the drug you are asking for. If the copay for a drug is higher than expected.

A coverage determination (exception) is a decision about whether a drug prescribed for you will be covered by us and the amount you'll need to pay, if any. If a drug is not covered or there are restrictions or limits on a drug, you may request a coverage determination.

What's a "Local Coverage Determination" (LCD)? LCDs are decisions made by a Medicare Administrative Contractor (MAC) whether to cover a particular item or service in a MAC's jurisdiction (region) in ance with section 1862(a)(1)(A) of the Social Security Act.

How to Request a Coverage Determination. An enrollee, an enrollee's prescriber, or an enrollee's representative may request a standard or expedited coverage determination by filing a request with the plan sponsor. Standard or expedited requests for benefits may be made verbally or in writing.