What is a coverage determination?:QuickMedicareSupplement.com

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What is a coverage determination?

What is a coverage determination?

A coverage determination is a Medicare drug plan's primary decision about the services a member can obtain as part of the plan's Medicare prescription drug coverage. This can consist of a decision whether or not to provide or pay for a drug, a decision about an exception request, a decision about a member's out-of-pocket costs (cost sharing) for a drug, or a decision about whether a member has met a prior authorization requirement for a requested drug.

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