Coverage Determinations and Exceptions
In order to make our coverage accessible and affordable, Windsor Rx requires certain drugs to be authorized in advance by us (Prior Authorization), limits the quantities that may be routinely dispensed for some drugs (Quantity Limits) and for certain drugs asks doctors to prescribe less costly alternatives first, among drugs in the same category (Step Therapy). For Specific information, please select from the following list:
Prior Authorization
Quantity Limits
Step Therapy
Coverage Determination and Exception Process
Prescriber Coverage Determination Contacts
Member Coverage Determination Contacts
To view the list of approved drugs (formulary) and related requirements and limits, please select the Member’s plan type from the following list:
To view an important announcement about the recall of the drug Zelnorm, click here.
To view an important announcement about the discontinuation of the drug Zyflo, click here.
To view an important announcement about the recall of the drug Wellbutrin XL®, click here.
To view an important announcement about the recall of the drug Neupro®, click here.
Formulary Changes 2008:
To view any changes we have made to our formulary, please select the link below:
To see special rules regarding drugs a member may be taking when first joining our plans, please click on the link below:
- View Transition Policy (PDF)
At Windsor Rx we recognize that individual circumstances may justify exceptions to these policies. To request an exception, or to request prior authorizations, please follow the Coverage Determination and Exception Process.
Click here to download and print the Coverage Determination Form (PDF)
Prior Authorizations (PA)
Windsor’s established prior authorization medications are recommended by the Windsor Pharmacy and Therapeutics Committee, which is a committee consisting of community physicians, pharmacists and nurses. Prior Approvals have been established to promote safe and appropriate cost-effective use of specific classes of medications. A prior authorization payment determination (also known as a coverage determination) is required before the member goes to the pharmacy. Please click on Coverage Determination and Exception Process for a description of the coverage determination process.
The following list represents a partial list of prior approvals in the Windsor system:
| Prior Approval Medications | |
| Aranesp Injection | Forteo Injection |
| Avonex Injection | Lamsil |
| Betaseron Injection | Pegasys Injection |
| Cellcept | Peg-Intron Injection |
| Copaxone Injection | Rebif Injection |
| Enbrel Injection | Tarceva |
| Epogen Injection | Testosterone |
| Exjade | Thalomid |
Please consult the applicable formulary for specific PA information
Quantity Limits (QL)
Windsor’s established quantity limit medications are recommended by the Windsor Pharmacy and Therapeutics Committee, which is a committee consisting of community physicians, pharmacists and nurses. Quantity limits have been established to promote safe and appropriate cost-effective use of specific classes of medications to ensure proper dosing. All quantity limits are listed on the formulary as an established number of units per 30 days. The system will count all units received within the therapeutic class and will only allow payment of the quantity established.
The process used to establish the limit of the identified drug is the current approved Food and Drug Administration (FDA) dosing. Prescribers may request an exception to Windsor’s quantity limits by following the Exception Process.
The following list represents a partial list of quantity limits currently in the Windsor system for commonly prescribed classes:
| Drug Class | QL Limit |
| All Narcotics (Example: Tramadol, Oxycontin, Hydrocodone) | 120 pills per 30 days per ALL drugs in the class |
| All Sleeping Pills (Example: Ambien, Sonata, Lunesta) | 30 pills per 30 days per ALL drugs in the class |
| Triptans (Example: Imitrex, Maxalt) | 12 pills per 30 days per ALL drugs in the class |
| Statins (Example: Lipitor, Zocor) | 30 pills per 30 days per ALL drugs in the class |
| PPIs (Example: Protonix, Prevacid) | 30 pills per 30 days per ALL drugs in the class |
Please consult the applicable formulary for specific quantity limit information.
Step Therapy (ST)
Windsor’s established step therapy medications are recommended by the Windsor Pharmacy and Therapeutics Committee, which is a committee consisting of community physicians, pharmacists and nurses. Step therapy medications have been established to maintain safe, effective treatment while keeping costs as low as possible. When step therapies are established, Step 2 medication will not be covered until Step 1 medications are first tried.
The following list represents a partial list of step therapies in the Windsor system:
| Step Therapy | Must try FIRST |
| Prevacid, Protonix | Prilosec OTC (no copay members) |
| Zyrtec | Generic first |
| Paxil, Zoloft, Prozac | Generic first |
Please consult the applicable formulary for specific step therapy information.
Coverage Determination and Exception Process
The processes outlined below are followed in making coverage determinations which include Prior Authorizations, Step Therapy, Quantity Limits, and amount of cost sharing for a drug or Tier Exceptions.
1. Call Windsor Pharmacy Department and request a coverage determination or exception (members call – 800-316-2273; physician call – 866-715-7519). If a Coverage Determination form is not available, all information may be given orally. A physician may use the Model Medicare Part D Coverage Determination Form or the Windsor Coverage Determination Form. If requesting an exception to a PA or other UM requirement (quantity limit, step therapy or tiering exception) in which a member would suffer adverse effects if he or she were required to satisfy the PA requirement, the prescribing physician must provide a written supporting statement or documentation to Windsor. Additionally, members may request tier and formulary exceptions, but they will not be processed until the member’s prescribing physician submits a coverage determination form with a written supporting statement or documentation.
2. After receiving the required information, the Coverage Determination will be reviewed by Windsor. If the request meets the established clinical criteria that has been recommended by the Windsor Pharmacy and Therapeutics Committee, which is a committee consisting of community physicians, pharmacists and nurses, approval of payment will be granted by Windsor.
3. If the Coverage Determination or exception is approved, the medication approved, date and length of the approval, are faxed back to the prescriber and mailed to the member. An override is then entered into the pharmacy claims processing system or the medical claims processing system depending on the delivery of the medication.
4. If the Coverage Determination or exception is denied, after not meeting established clinical criteria that has been recommended by the Windsor Pharmacy and Therapeutics Committee, which is a committee consisting of community physicians, pharmacists and nurses, denial notification of payment will be mailed to the prescriber and member. The letter of non-coverage of the requested drug is generated and includes the following: the name of the denied medication, the specific clinical reasons that coverage was denied, a statement that the clinical criteria is available upon request and free of charge, the notice of the right to file an appeal, and whom to contact for more information. The appeals process is available for any denial.
5. Coverage Determinations will be processed per with the following timeframes:
| TYPE OF COVERAGE DETERMINATION / TIERING EXCEPTION | TIMEFRAME |
| STANDARD coverage determinations and tiering exceptions | As expeditiously as the member’s health condition requires, but no later than 72 HOURS after receipt of the request/supporting statement |
| EXPEDITED coverage determinations and tiering exceptions | As expeditiously as the member’s health condition requires, but no later than 24 HOURS after receipt of the request/supporting statement |
6. Windsor Part D Members have the following rights:
- The right to a timely coverage determination.
- The right to request an expedited coverage determination.
- The right to receive information from a network pharmacist regarding the member's ability to obtain a detailed written notice from Windsor regarding the member's Part D Benefits.
- The right to a detailed written notice of Windsor's decision to deny a benefit in whole or in part, which includes the member's appeal rights.
- The right to receive notice when a coverage determination is forwarded to the Independent Review Entity (IRE).
7. If Windsor does not provide notice of its standard or expedited coverage determination within the required time frame, the complete case file will be forwarded to the Independent Review Entity (IRE) contracted by CMS within 24 hours of the expiration of the adjudication time frame. Windsor must have the prescribing physician written supporting statement before sending to the IRE.
Coverage Determination Contacts for Prescribers
By Telephone or Fax:
Windsor Medicare Extra Plans
Phone: (866) 715-7519 or (615) 782-7961
Fax: (615) 782-7869
Windsor Rx
Phone: (866) 715-7520 or (615) 782-7962
Fax: (615) 782-7869
Tennessee Choice + Rx
Phone: (866) 715-7495 or (615) 782-7960
Fax: (615) 782-7869
All Plans After Hours Phone: (615) 557-2453
Windsor Medicare Extra
Attn: Pharmacy Department
7100 Commerce Way
Suite 285
Brentwood, TN 37027
Coverage Determination Contacts for Members
Windsor Medicare Extra Plans
Phone: (866) 316-2273 or (615) 782-7878
Windsor Rx
Phone: (866) 875-4068 or (615) 782-7969
Tennessee Choice + Rx
Phone: (866) 316-2273 or (615) 782-7878
All Plans After Hours Phone: (615) 557-2453
Windsor Medicare Extra
Attn: Pharmacy Department
7100 Commerce Way
Suite 285
Brentwood, TN 37027
