Certificate of Creditable Coverage · Prior Health Insurance Plan / Employer
Certificate proving prior health insurance coverage, used when enrolling in a new plan to avoid pre-existing condition exclusions or late enrollment penalties (particularly for Medicare Part D).
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Request from your prior health plan's member services department
Fax request to prior plan's enrollment or member services
Request through the prior plan's member portal (if available)
Filing Deadline
Your prior plan must provide the certificate automatically upon loss of coverage and upon request within 24 months of coverage ending.
Typically provided within 2-4 weeks of request. Some plans provide it automatically at termination.
Provide the certificate to your new health plan to document your prior coverage period. This is especially important for Medicare Part D enrollment to avoid late enrollment penalties.
PA Request (insurer-specific) · Health Insurance Plans
Request for approval of surgical procedures, imaging studies, specialist referrals, or other services requiring pre-authorization. Must demonstrate medical necessity.
Pharmacy PA (insurer/PBM-specific) · Health Insurance Plans / PBMs
Request for coverage of formulary drugs requiring PA, non-formulary drugs, or override of step therapy, quantity limits, or other utilization management edits.
Step Therapy Exception · Health Insurance Plans / PBMs
Request to bypass step therapy requirement and proceed directly to a preferred or non-preferred drug. Must document why first-step drugs are not appropriate for the patient.
Tiering Exception · Part D Plans / Commercial Insurers
Request to obtain a non-preferred drug at the lower cost-sharing tier. Prescriber must provide a supporting statement documenting why the lower-tier alternatives are not appropriate.
Specialty PA (insurer-specific) · Health Insurance Plans / Specialty Pharmacies
Prior authorization request for high-cost specialty medications including biologics, gene therapies, and other complex drugs. Requires detailed clinical criteria documentation.
DME PA (insurer-specific) · Health Insurance Plans / Medicare MACs
Request for coverage of wheelchairs, CPAP machines, hospital beds, prosthetics, orthotics, and other durable medical equipment.
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