Each drug plan must have an appeals process. Expedited requests are available.<\/p>\n
Stages of Review
\nCoverage Determination
\nA coverage determination is issued by the drug plan. It may be requested by a beneficiary, the beneficiary\u2019s appointed representative, or a prescribing physician. The drug plan must issue a coverage determination as expeditiously as an enrollee\u2019s health requires, but no later than 72 hours (for a standard request, including when the beneficiary already paid for the drug) or 24 hours (if expedited because the standard timeframe would jeopardize the life or health of the beneficiary or the beneficiary\u2019s ability to regain maximum function).<\/p>\n
An \u201cexception\u201d is a type of coverage determination. It gets the enrollee into the appeals process. Beneficiaries may request an exception to cover non-formulary drugs, to waive utilization management requirements, and to reduce cost-sharing for a formulary drug. There is no exception for specialty drugs or to reduce the costs of tiered co-pay for (more…)<\/span><\/a><\/p>\n","protected":false},"excerpt":{"rendered":" Each drug plan must have an appeals process. Expedited requests are available. Stages of Review Coverage Determination A coverage determination is issued by the drug plan. It may be requested by a beneficiary, the beneficiary\u2019s appointed representative, or a prescribing…<\/span><\/p>\n