Last Updated: Tuesday, September 21, 2021
Pharmaceutical management procedures encompass programs such as prior authorization, managed prescription drug coverage (MCxC), and Formulary Management. Physicians may request coverage for a product from any of these programs.
Physicians may submit requests for drug coverage if all of the following criteria are met:
All requests will be considered standard unless the requesting physician indicates the need for an expedited review. For standard requests, a decision will be communicated within two business days after receipt of all supporting information reasonably necessary to complete the review. For expedited requests, a decision will be rendered as expeditiously as the member's health requires, but no later than one business day (not to exceed 72 hours). Expedited requests will be limited to those instances where:
If you need a copy of the medication request form, print it from your computer, and complete it in accordance with the directions below.
Please note that this form is only applicable for those members who have a closed formulary benefit design or prior authorization. Requests are for individual patients only.
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Your message should include all necessary information found on the request form. We suggest using the request form as a template when you call in order to avoid unnecessary delays in processing your request. Please note that the use of the voice mail system is reserved for expedited requests only.
When an exception request is approved, both the physician and the member will be notified of the approval. When an exception request is denied, both the physician and the member will be notified of the denial. The member's denial letter explains the right to file a grievance or appeal if he or she considers the decision unacceptable.
A member who is not satisfied with the outcome of a decision may file a grievance through the Initial Grievance Committee. Information on the initial grievance process appears in the member's handbook.