Manage Your Plan
Get Coverage for Your Prescription Drugs
If you are a new member, you may also be interested in our Coverage Transition Policy.
Step 1 - Determine if your medicine is covered.
Look up your current prescription drugs using our Searchable Formulary. This will tell you if Community CCRxSM covers your prescription medicine.
Step 2 - What do I do if my medicine is not covered?
If your medicine is not covered, the Searchable Formulary will give you with a list of similar medicines we cover. If you wish, you can speak with your doctor to determine if he or she will write a prescription for the alternative medicine.
You also can request a coverage determination. A coverage determination is initiated by you and/or your doctor and is a request for Community CCRx to cover a drug that is not currently included in our formulary. There are five types of coverage determinations, detailed in the page about Restrictions to Our Covered Drugs.
Step 3 - Complete Form
If you wish to pursue a coverage determination for your non-covered medicine, you must complete the appropriate form for the type of coverage determination you are requesting:
The easiest way to find the correct form for your drug is to use the Searchable Formulary. Simply type the name of your drug, and you can print the form.
You may also wish to view a list of Exception and Prior Authorization Forms.
Print out the form and ask your doctor to fill it out. Your doctor should also include as much supporting documentation as possible to avoid delays in your request.
Step 4 - Submit Form To Community CCRx
Once your doctor has completed the form, either you or your doctor can:
Mail the form to:
Community CCRx
Appeals/Coverage Determinations
P.O. Box 391197
Solon, OH 44139-3911
Or, you can fax your appeal request to us at: 1-866-868-0858.
You may also file an appeal by phone. Call us at 1-866-316-6049 (TTY/TDD users call 1-866-684-5351), or if you have any general questions about the appeals process.
Step 5 - Notification
You and your doctor will be notified of our decision by US mail. If the decision is not in your favor, the letter will include a list of alternative medicines that are on our formulary, if there are any, and instructions on how file an appeal (re-determination).
For any questions about the coverage determination process, or the status of an existing request, please call: 1-866-316-6049.
What if my coverage determination is denied?
If we deny all or part of your coverage determination request, you or your appointed representative may ask us to reconsider our decision. This is called an appeal or re-determination.