Coverage Determination Request Form

A coverage determination is any decision made by a health plan regarding coverage benefits to which a plan enrollee believes he or she is entitled. In this case, the decision would be made regarding coverage of a specific prescription drug regimen.

Request a Coverage Determination

Getting Started

If you would like to request a coverage determination, make an exception to the rules or restrictions on our plan’s coverage of a drug that you are currently taking, or if your provider is planning for you to take a drug restricted by our plan, you may download the Coverage Determination Request Form below and submit it to us via mail or fax.

If you need assistance, you can always contact Pharmacy Member Services at:

1-800-891-6989 (TTY 711)

Download the Coverage Determination Request Form:

Once complete, you can mail the form to:

P.O. Box 25183
Santa Ana, CA 92799

or call us directly at: 1-800-891-6989

Redetermination of a Medicare Prescription Drug Denial

Request for Redetermination

If you or your provider disagree with a coverage decision made by the plan, you can download and submit the following Request for Redetermination of Medicare Prescription Drug Denial Form.

This is considered an appeal of a coverage determination.

Download the Redetermination of Medicare Prescription Drug Denial Form.

Once complete, you can mail the form to:

OptumRx Prior Authorization Appeals
P.O. Box 2975
Mission, KS 66201

or call us directly at: 1 (888) 403-3398

Page Last Updated On: February 13, 2023
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Tom Cunniffe

Tom Cunniffe

Director of Operations 

Tom Cunniffe comes to eternalHealth with over 20 years of healthcare operations’ experience, having held leadership positions in Call Center, Enrollment, Credentialing, UAT and Reimbursement teams. Tom has worked with Medicaid, Commercial and Medicare lines of business and has consistently built teams who are metrics driven with proven successful outcomes. Making sure our business strives for an efficient, best-in-class customer experience is at the center of Tom’s philosophy.

Tom has a bachelor’s degree from Fordham University and a master’s in business administration from University of Massachusetts at Amherst.

Tom Lawless

Tom Lawless

Chief Financial Officer

Tom Lawless has spent the past 20+ years building, sustaining, and growing new healthcare-related programs that balance fiscal responsibility & prudence with creativity & innovation, focusing on models of care that are novel, person-centered, and improve the social welfare of those who are served. He is very excited to continue doing so in his role as the Chief Financial Officer of eternalHealth.

Tom comes to eternalHealth from a not-for-profit, member-centric, health insurance cooperative. He helped the company continuously strive toward its dual goals of thriving financially, while keeping members at the very epicenter of its mission and service model. While there, Tom also spearheaded the creation of a brand new private, charitable foundation, which will be meaningfully giving back to those in need in the surrounding communities for years to come. Previously, Tom worked in the finance department of a successful hospice that provided high-quality care to persons experiencing their unique and poignant end-of-life journeys, assuring that the appropriate financing was always available. Tom’s career began as a civil servant in the Wisconsin Medicaid program, where he helped to create a program that expanded the institutional entitlement to care into home and community-based settings. Starting with only a blueprint in hand, the program now serves more than 57,000 frail elders and disabled adults and is considered a national model. Growing into a senior leadership role, Tom was a key architect of an innovative financing model, through which the public and private sectors successfully collaborated to better the lives of persons in great need.

Tom holds undergraduate and graduate degrees from the University of Chicago, with additional graduate work in economics completed at the University Wisconsin-Madison.

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