Some prescription drugs must be authorized by the US Family Health Plan before the service is delivered. Asking for a “Prior Authorization” is the starting point of this process.
If a certain prescription drug is not covered under your plan or if a Prior Authorization appeal request is denied, you can apply for an appeal or override.
For the most accurate, personalized benefit and coverage information tailored to you, sign in to your member account.
Sometimes, when you’re at the pharmacy, you might find that your medication claim has been denied. We know this can be frustrating, and we’re here to help make things right.
Here’s what you need to know:
Prior Authorization RequirementFor plans with a deductible: If your prescription needs prior authorization, it means we need a bit more information before we can approve it. Please get in touch with your doctor to initiate start this process, as we cannot override this requirement.
More information on the prior authorization process can be found below.
Mail-Order Pharmacy Requirement"Maintenance medications" (prescription drugs you take for ongoing conditions like high blood pressure, high cholesterol, etc.) must be filled using our Mail-Order Pharmacy service. Exceptions include:
Filling Too EarlyDo you need your prescription medication before your next scheduled refill?
There are a few scenarios where we can help:
Medication Not CoveredIf the medication is not covered under your plan, this claim cannot be overridden. Please discuss alternative medications that are covered with your health care provider.
Quantity or Cost IssuesIf there’s a problem or an issue with the quantity or cost of your medication, we can review the situation to see if an override is possible.
Overrides are intended to be exceptions to ensure the provision of necessary care when needed. They are not standard procedure, and each case is assessed individually to provide the best solution.
If you are in a situation that you believe requires an override, there are three steps to take:
Immediately call one of the following teams:
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If your prescription needs prior authorization, it means we need a bit more information before we can approve it. Please get in touch with your doctor to initiate start this process, as we cannot override this requirement.
It is your provider’s responsibility to request authorization from the US Family Health Plan to request coverage for certain prescription drugs/services. After the review, the Plan will send an authorization approval or denial letter to the beneficiary and the provider explaining the coverage decision.
Note: Baby formula is not covered, even if a prior authorization is granted by the Health Management Department.
Depending on the drug as well as diagnosis information, some Prior Authorizations can expire.
The expiration date depends on several factors and can vary—some expire after six months and others expire after one year. Some Prior Authorization approvals are "forever", meaning there is not an expiration date.
Depending on the medication, members may receive a letter detailing that the prior authorization will expire. The expiration date would be included in the mailed letter.
NOTE: The letter is not sent to primary care providers or specialists who prescribed the medication or submitted the prior authorization.
Once the prior authorization form is filled out completely, the turn around time is generally 1-2 business days, but can take up to 14 days.
The time frame may be longer if we don’t have the information necessary to make a determination. If there is additional clinical information required, we will reach out to your provider for that information.
If you are a new member and have an active prior authorization through another insurance plan (including another TRICARE® plan), you must provide documentation. Any active prior authorizations will be considered as part of the Martin's Point prior authorization process.
If you cannot provide the necessary documentation, you will need to obtain a new authorization through the US Family Health Plan.
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Members who are not satisfied with medical decisions made by the US Family Health Plan or who disagree with the US Family Health Plan decision to deny an authorization or claim, may pursue the formal appeals process.
When an authorization is denied, an appeal can be requested within 90 days of the authorization denial date. Your provider will help you file the necessary appeal documentation.
There are two main types of appeals:
A factual appeal is a request to reconsider a claim or an authorization request that has been denied for any of the following reasons:
Medical-necessity appeals are requests to reconsider a claim or an authorization request that has been denied for any of the following reasons:
Appeals must be filed, in writing, within 90 calendar days after the date of the notice of the initial denial determination in order to be accepted for review. Appeals can be submitted by mail, fax, or by email.
Appeals may be submitted by a member, the member’s appointed representative, the parent of a minor, or a provider (if the member has signed an Appointment of Representative form authorizing the provider to act on their behalf).
If you would like someone to act on your behalf during the appeal process—including a family member, caregiver, or provider—you must first complete and submit the Appointment of Representative (AOR) form. This form legally authorizes your chosen representative to communicate with us regarding your appeal and receive relevant information. Complete this form before submitting your appeal.
All appeals should include the following information:
Martin's Point US Family Health Plan
Attn: Appeals Specialist
PO Box 8832
Portland, ME 04104
The required information can be faxed to the following number:
207-828-7849
Once an appeal letter is received, the US Family Health Plan will mail you an acknowledgment letter confirming receipt and stating when a final determination of your appeal request will be made, following TRICARE guidelines. The US Family Health Plan will issue a written determination letter once the appeal is processed.
Expedited appeals must be medical-necessity appeals and be submitted prior to the service being delivered. They must be filed within three (3) calendar days after the date of the mailing of the initial denial determination. An appeal can be expedited for the following reasons:
For concurrent appeals, the member must be a patient in the facility on the date of the appeal filing.
Search our Forms & Documents database to access the prior authorization forms and related documents for US Family Health Plan members:
All prior authorization forms can be found by using the Forms & Documents Search Tool:
If you are a provider and have questions, contact Martin's Point and one of our representatives can assist you:
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Whether you’re exploring plan options or already a US Family Health Plan member, our team is ready to help.
Prospective Members: Call us at 1-877-757-7087
Current Members: Call Member Services at 1-888-674-8734