External exception request review Sample Clauses

External exception request review. If we deny a request for a standard exception or for an expedited exception, the member, the member’s designee or the member’s prescribing physician may request that the original exception request and subsequent denial of such request be reviewed by an independent review organization. We will make our determination on the external exception request and notify the member, the member’s designee or the member’s prescribing physician of our coverage determination no later than 72 hours following receipt of the request, if the original request was a standard exception, and no later than 24 hours following its receipt of the request, if the original request was an expedited exception. If we grant an external exception review of a standard exception request, we will provide coverage of the non-formulary drug for the duration of the prescription. If we grant an external exception review of an expedited exception request, we will provide coverage of the non-formulary drug for the duration of the exigency. Notice and Proof of Loss: In order to obtain payment for covered service expenses incurred at a pharmacy for prescription orders, a notice of claim and proof of loss must be submitted directly to us. Non-Covered Services and Exclusions: No benefits will be paid under this benefit subsection for services provided or expenses incurred: