Medical review and actions when transition claims pay

The Company conducts medical review and coverage determinations for prior authorization (PA), step therapy (ST), quantity limit (QL) and non‑formulary drug requests; when a transition claim pays the plan provides a transition letter to member and prescriber, allows the prescriber to suggest formulary alternatives, and enables initiation of PA/exception requests as needed. Members are notified of appeal/redetermination rights when denials occur and appeals/redeterminations are available if a PA or exception is denied.

• Provide transition letter to member and prescriber when transition claim pays.
• Prescriber may suggest/formulary alternatives or initiate PA/exception if no appropriate alternative.
• Appeals/redetermination available and expedited on request when denials occur.

Point-of-sale UM edits and adjudication during transition

At point-of-sale the Company resolves step therapy and prior authorization edits by allowing paid transition claims and applies only limited UM edits during transition: Part A/B vs Part D determinations, prevention of coverage for non‑Part D drugs, and edits to promote safe utilization.

• Step therapy and prior authorization edits are resolved at POS through paid transition claims.
• Applied POS UM edits: Part A vs B/D determinations, non‑Part D prevention, and safe utilization edits.

One-time authorizations for level-of-care changes

When a level-of-care change is not automatically identified, the pharmacist must call the Pharmacy Help Desk to notify them so a one-time authorization can be entered to allow the claim to pay; these are entered as one-time authorizations and additional one-time authorizations are placed for subsequent level-of-care changes.

• Pharmacist calls Pharmacy Help Desk to report level‑of‑care change if system did not auto-identify.
• Help Desk places a one-time authorization to allow the claim to pay.
• Enter additional one-time authorizations for subsequent level‑of‑care changes to prevent therapy gaps.

Overrides at POS and beneficiary exception/appeal rights

If UM edits are overridden at point‑of‑service solely for transition fills, the beneficiary is notified and may begin the formulary exception process; all non‑formulary, PA, ST, or QL edits remain subject to exception and appeal procedures.

• Overrides at POS for transition-only fills trigger beneficiary notification (transition letter).
• Beneficiary may initiate an exception request and pursue appeals/redeterminations if needed.
• Non‑formulary, PA, ST, and QL edits remain subject to exception and appeal even when waived for transition.

Availability and submission methods for PA/exception requests

Prior authorization and formulary exception request forms are available upon request to enrollees and prescribers via mail, fax, email, and plan sponsor websites; requests may be initiated by the beneficiary, authorized representative, prescriber, or pharmacy and submitted in writing, by phone, email, or fax.

• PA/exception forms provided for convenience via mail, fax, email, and plan websites.
• Requests may be submitted by beneficiary, authorized representative, prescriber, or pharmacy.
• Submission methods include written, telephonic, email, or fax.

Case‑by‑case extension of transition period when appeals/requests pending

The Company will extend the transition period on a case‑by‑case basis when an exception request or appeal has not been processed by the end of the minimum transition period; extensions must be initiated by the beneficiary, authorized representative, prescriber, or pharmacy and may be requested in writing, by phone, email, or fax.

• Extensions provided until a transition is made or a decision on the exception request is issued.
• Initiation permitted by beneficiary, authorized representative, prescriber, or pharmacy.
• Requests accepted in writing, telephonically, by email, or by fax.

Attachments

Attachments: None. There are no attachments associated with this policy.