Care Practitioner. If You have a health condition that may jeopardize Your life, health, Your ability to regain maximum function or You are undergoing a current course of treatment using a drug that is not on the Drug List, an expedited review may be requested. You, or Your prescribing Physician or other Health Care Practitioner, will be notified of the coverage decision within 24 hours after the request for expedited review is received. If Your request is granted, coverage will be provided for the duration of the exigency. For requests that do not meet the criteria for expedited review, a standard review will be completed and You and Your prescribing Physician or other Health Care Practitioner will be notified of the coverage decision within 72 hours after the request for standard review is received. If Your request is granted, coverage will be provided for the duration of the prescription, including refills. If Your expedited or standard Drug List exception request is denied, the decision notice will include information explaining Your right to request review by an Independent Review Organization (IRO). You and Your prescribing Physician or other Health Care Practitioner will be notified of the IRO’s decision within 24 hours of an expedited review and within 72 hours for a standard review. If Your expedited exception request is granted, coverage will be provided for the duration of the exigency. If Your standard exception is granted, coverage will be provided for the duration of the prescription, including refills.
Care Practitioner. If You have a health condition that may jeopardize Your life, health or Your ability to regain maximum function or You are undergoing a current course of treatment using a drug that is not on the Drug List, an expedited review may be requested. You, or Your prescribing Physician or other Health Care Practitioner, will be notified of the coverage decision within 24 hours after the request for expedited review is received. If Your request is granted, coverage will be provided for the duration of the exigency. For requests that do not meet the criteria for expedited review, a standard review will be completed and You and Your prescribing Physician or other Health Care Practitioner will be notified of the coverage decision within 72 hours after the request for standard review is received. If Your request is granted, coverage will be provided for the duration of the prescription, including refills. If Your expedited or standard Drug List exception request is denied, the decision notice will include information explaining Your right to request review by an Independent Review Organization (IRO). You and Your prescribing Physician or other Health Care Practitioner will be notified of the IRO’s decision within 24 hours of an expedited review and within 72 hours for a standard review. If Your expedited exception request is granted, coverage will be provided for the duration of the exigency. If Your standard exception is granted, coverage will be provided for the duration of the prescription, including refills Day Supply. Benefits for Covered Drugs obtained from a Participating Pharmacy are provided up to the maximum day supply limit as shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. HMO has the right to determine the day supply. Payment for benefits covered by HMO may be denied if drugs are dispensed or delivered in a manner intended to change, or having the effect of changing or circumventing, the stated maximum day supply limitation. Extended Prescription Drug Supply Program. Your coverage includes benefits for up to a 90-day supply of covered maintenance type drugs purchased from a Participating Pharmacy (which may only include retail or mail order Pharmacies). Each prescription or refill is subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and any applicable pricing differences. Benefits will not be provided for more than a 30-day supply of drugs purchased from a Pharmacy not participating in the extended prescription drug s...
