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Gateway Health Medicare Assured Plans

Formulary Exceptions



You can ask Gateway Health Medicare Assured (Gateway) to make an exception to our coverage rules**.  Contact us from 8:00am-8:00pm, 7 days per week:

Pennsylvania Residents:   Call 1-800-685-5209

TTY users should call 711

Ohio Residents:   Call 1-888-447-4505

TTY users should call 711

North Carolina Residents:   Call 1-855-847-6430

TTY users should call 711

Kentucky Residents:  Call 1-855-847-6380

TTY users should call 711

You can also make a request via Gateway’s secure member portal.  To register for an account, click here.

You can also mail or fax your request to**:

Address

Gateway Health Medicare Assured
P.O. Box 22158
Pittsburgh, PA 15222-1222

Fax Number

 1-888-447-4369

**If the request is submitted by the member, the prescribing physician or other prescriber must submit a statement to support the request for coverage determination. The physician or other prescriber should also indicate whether or not the member’s health could be seriously harmed by waiting three days for a decision on this request.

There are several types of exceptions that you can ask us to make:

You can ask us to cover your drug even if it is not on our formulary.

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Gateway Health Medicare Assured limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

If your drug is in a cost-sharing tier and you think the cost is too high, you can ask for us to cover your drug at a lower cost-sharing tier. We do not lower the cost-sharing amount for drugs in the Specialty tier.

Generally, Gateway will only approve your request for an exception if the alternative drugs included on the plan’s formulary or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you are requesting a formulary or utilization restriction exception you must submit a statement from your physician supporting your request.  

Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement.  Your physician can contact Gateway via phone or complete the Medicare Drug Exception Form (pdf).

What if my request for exception is denied?

You have the right to request Reconsideration (redetermination) of this denial.  To file your request by phone:

Pennsylvania Residents:   Call 1-800-685-5209

TTY users should call 711

Ohio Residents:   Call 1-888-447-4505

TTY users should call 711

North Carolina Residents:   Call 1-855-847-6430

TTY users should call 711

Kentucky Residents:  Call 1-855-847-6380

TTY users should call 711

Or you can use the Reconsideration form to file your request.  Your doctor may also make this request for you. 

If you wish to have someone else make this request for you, you must include a completed Gateway Health Medicare Assured Appointment of Representative Form (pdf) to give this person permission. 

If you wish to send us your request in writing, you may fax it to us at 412-255-4503.  You may hand deliver or mail your request to this address:

Gateway Health
Attention: Appeals & Grievances
P.O. Box 22278
Pittsburgh, PA 15222

You may also wish to refer to the Gateway Health Medicare Assured Evidence of Coverage for further details about the reconsideration process and further appeal options. 

Gateway Health offers HMO plans with a Medicare Contract. Some Gateway Health plans have a contract with Medicaid in the states where they are offered. Enrollment in these plans depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium – The State pays the Part B premium for full dual members. Please contact the plan for further details. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

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