Common use of As Requested Clause in Contracts

As Requested. a. Any member who receives a prescription for a new FDA approved specialty drug that is not on the approved Specialty Drug List as of January 1, 2012 (attachment A), and therefore not covered by the Health Care Plan, may submit a request to the Plan Administrator who in turn will submit the request to the P&T Committee for a review and recommendation. The P&T Committee will convene within a reasonable period of time appropriate to the circumstances (emergencies will be treated as such) and make a recommendation as listed in (1) (b) above. Adverse determinations can be appealed as referenced below 1) Pre-Authorization of approved Specialty Drugs will continue to be processed in accordance with current procedures of the Health Plan utilized by the Pharmacy Benefit Manager for evaluation of medical necessity. Appeals of adverse determinations of Special Drug Coverage will follow the current appeal process located in the Summary Plan Document under the “How to Submit a Claim” section. In the event that genetic testing is required to determine if the requested drug is medically appropriate for treatment of the individual’s condition, the member must satisfy that criteria before the pre-authorization review can be completed.