Members Resources

If a drug is not covered  by Perennial Advantage, you can ask the plan to make an “exception.” An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor or another prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request.

You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of good cause for missing the deadline may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.

A coverage determination may be requested by any of the following:

• You or your representative may request a coverage determination.
• Your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) can request a coverage determination for you on your behalf.

To request a coverage determination, ask your provider or prescriber to visit this page.

Provider or Prescriber instructions:

To request a coverage determination, including an exception, from AgeRight Advantage, visit Navitus to login to access the form or fill out:

To request a Medicare Prescription Drug Appeal (Redetermination) visit Navitus to login to access the form or fill out:

Fax or mail the completed form to Navitus at:

(844) 268-9791

Perennial Advantage
PO Box 908
Addison, TX 75001-0908

You may also contact our Member Services Department at:

• 1-844-788-6959 (TTY 711) for Colorado
• 1-844-788-6986 (TTY 711) for Ohio

and request the fax number for Appeals and Grievances.

Your provider may also request an exception or expedited exception by contacting the Pharmacy Help Desk at 1-866-270-3877 (TTY 711) 24 hours a day, and 7 days a week.

Our plan has seventy-two (72) hours (for a standard request) or twenty-four (24) hours for an expedited request) from the date it gets your request to notify you of its decision.

A coverage determination may be requested for any of the following:

• Covering a Part D drug for you that is not on the list of covered drugs (formulary).
• If your health care provider or prescriber believes you need a drug that isn’t on the list of covered drugs (formulary).
• If your network pharmacy can’t fill a prescription as written.
• To remove a restriction for a covered drug.
• If you or your prescriber believe that a coverage rule (such as prior authorization) should be waived.
• Changing coverage of a drug to a lower cost-sharing tier. 
• If you think you should pay less for a higher-tier drug because you or your prescriber believe you can’t take any of the lower-tier drugs for the same condition.
• Request for payment.

Your doctor or other prescribers must give us a written statement that explains the medical reasons for requesting an exception. For a faster decision, include medical information from your doctor or other prescribers when you ask for the exception.

Perennial Advantage can accept or deny your request.

If we approve your request for an exception, our approval usually is valid until the end of the plan year. This is true if your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.

If we say no to your request for an exception, you can ask for a review of our decision by making an appeal. If your health requires a quick response, you must ask us to make a “fast decision”.