Commercial Medication Exception Review Process
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Governs McLaren Health Plan's prior authorization (PA) and formulary exception process for commercial medications, describing how members and prescribers request standard and expedited reviews, internal review outcomes, and appeal pathways. Affects MHP commercial members, their prescribing providers, and PBM staff.
No material clinical or coverage changes in this revision.
Coverage criteria and process
Coverage criteria and process
Covered when the following conditions and procedural requirements are met:
ALL of the following
- Submit a completed MedImpact Request for Prior Authorization form with supporting documentation by fax to MedImpact (Fax: (858) 790-7100) or call the MedImpact Help Desk (888-274-9689, TTY 711) to begin the process.
- For expedited (exigent) review, select the REQUEST FOR EXPEDITED/URGENT REVIEW option on the PA form and fax or call MedImpact to initiate an expedited review.
- Standard formulary exception determinations: MHP will notify the member (or authorized representative) and the prescriber within 72 hours of receipt of the request.
- Expedited/exigent determinations: MHP will notify the member (or authorized representative) and the prescriber within 24 hours of receipt of the request.
ALL of the following
- Approved: PBM pharmacist contacts MHP CMO/authorized representative; if approved, PBM will enter an authorization (override) into the member's electronic profile for the length of time approved by the health plan (no additional precertification number required at the dispensing pharmacy).
- Pending: MHP requests additional information; PBM will contact the prescriber for supporting documentation and all Utilization Management timeframes apply.
- Denied: The CMO or authorized representative denies the request; MHP Utilization Management denial and appeals policies apply and the member has the right to appeal.
ALL of the following
- If prior authorization procedures are not followed, the PA request may be withdrawn and the medication may be non-covered; the member may be responsible for full charges.
ALL of the following
- If denied, the member may file internal appeals per MHP policy (see appeals procedures); timelines for standard and expedited reviews apply to appeals as well.
ALL of the following
- If approved, the PBM will enter the authorization for the length of time approved by MHP into the member's electronic profile.
Authorization duration and coding notes
| No specific billing, CPT, HCPCS, NDC, or ICD-10 codes are listed in this document. |
How providers submit requests and what happens next
Standard prior authorization submission
Complete the MedImpact Request for Prior Authorization form and submit it with all supporting documentation by fax to MedImpact at (858) 790-7100 or begin the process by calling the MedImpact Help Desk at (888) 274-9689 (TTY 711).
- Use the MedImpact Standard MRF (Request for Prior Authorization).
- Fax completed form and supporting documentation to MedImpact: (858) 790-7100.
- Or call MedImpact Help Desk 24/7 to begin the process: (888) 274-9689 (TTY 711).
Expedited prior authorization submission
Indicate urgent need by selecting the REQUEST FOR EXPEDITED/URGENT REVIEW option on the PA form, then fax the completed form and supporting documentation to MedImpact (Fax: (858) 790-7100) or call the MedImpact Help Desk to initiate the expedited review.
- Select REQUEST FOR EXPEDITED/URGENT REVIEW on the PA form.
- Fax completed expedited request and documentation to MedImpact: (858) 790-7100.
- Or call MedImpact Help Desk (888) 274-9689, TTY 711 to initiate expedited (exigent) review.
Internal review steps and communications
A PBM pharmacist will review the request for content and will contact MHP’s Chief Medical Officer (CMO) or an authorized representative for benefit determination; if more information is needed, the PBM will contact the prescriber.
- PBM pharmacist reviews the exception/PA request for content.
- PBM contacts MHP CMO or authorized representative for review and benefit determination.
- If pending, PBM will contact the prescriber to request additional information.
Approval processing
If the request is approved, the PBM will enter an authorization (override) into the member’s electronic profile for the length of time approved by MHP; once approved, the dispensing pharmacy will not need a special precertification/prior authorization number.
- Authorization (override) entered into member electronic profile for approved duration as directed by MHP.
- Dispensing pharmacy will not require a special PA/precertification number after approval.
Denial risk for not following procedures
Failure to follow the PA procedures may result in withdrawal of the PA request and the medication being non‑covered; the member may be responsible for full charges.
- If PA procedures are not followed, the PA request may be withdrawn.
- Non-coverage may result and the member may be liable for full charges.
Key definitions
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