Pharmacy appeals. Pharmacy appeals and Pharmacy Lock-In Program appeals must identify the matter being appealed and should include the member’s (and dependent’s, if applicable) name, the date the member attempted to fill the pre- scription, the prescribing physician’s name, the drug name and quantity, the cost of the prescription, if applicable, and any applicable reason(s) relevant to the appeal including: the reason(s) the member believes the claim should be paid, the reason(s) the member believes s/he should not be included in the Pharmacy Lock-In Program, and any other written documentation to support the mem- ber’s belief that the original decision should be overturned.
Pharmacy appeals. If a member requests a prescription drug that is on the formulary (covered drug), but the request is denied, the member can file an appeal. Appeal information will be included on the notice of denial. If the first appeal is denied, you can request a second-level appeal. If the second appeal is denied, the member can request an external review using information included in the appeal denial notice. If a drug is not on the formulary (not covered), it may be helpful to discuss other covered alternatives with your Physician; or, if not medically viable, you may request a formulary exception. An exception request may be made by the Member, the Member's designee, or the Member's prescribing Provider (or other prescriber, as appropriate) to request and gain access to clinically appropriate drugs not otherwise covered by the health plan (i.e. non formulary) by contacting us at 000-000-0000. We will work with the prescribing physician to obtain any medical records or other necessary information to process the request. We must act on a standard request within 72 hours and on an expedited request within 24 hours after we receive your request for a formulary exception. Expedited requests are available only when you have exigent circumstances: a health condition that may seriously jeopardize your life, health, or ability to regain maximum function or when you are undergoing a current course of treatment using a non-formulary drug. For a standard formulary exception, we will notify you no later than 72 hours following receipt of the request, and if approved, will provide coverage of the approved non-formulary drug for the duration of the prescription, including refills. For an expedited formulary exception, the determination will be made no later than 24 hours following receipt of the request and, if approved, will provide coverage of the non-formulary drug only for the duration of the exigent circumstances. If your formulary exception request is denied, you can ask for an appeal or an external exception review. The request can be made by you, your designee, or your prescribing Provider. You can ask for an exception review by contacting us to begin the process at: Prior Authorization Department P.O. Box 25183 Santa Ana, CA 92799 Fax: 000-000-0000 External exception reviews are available. The external exception review will be assigned to an independent review organization that will make a determination on your exception review. We will notify you or your designee, along ...
