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Coverage Determination Request

The coverage determination process ensures that medication regimens that are high risk, have a high potential for misuse, or have narrow therapeutic indices are used appropriately and according to FDA-approved indications.

You may request a coverage decision and/or exception any of the following ways:  

'Ohana Health Plans, Pharmacy-Coverage Determinations
P.O. Box 31397
Tampa, FL 33631-3397

For overnight requests:

'Ohana Health Plans, Pharmacy-Coverage Determinations
8735 Henderson Road, Ren. 4
Tampa, FL 33634

Basis for Requests

Providers may request coverage or exception for the following:

  • Drugs not listed in the Formulary
  • Duplication of therapy
  • Prescriptions that exceed the FDA daily or monthly quantity limit
  • Drugs that have an age limitation
  • Drugs listed on the PDL but still requiring Prior Authorization (PA)
  • Brand name drugs when a generic exists
  • Drugs that have a step edit (ST) and the first-line therapy is inappropriate
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Last Updated On: 9/3/2019
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