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Most of our Provider Policies are currently
undergoing review and will be posted soon.
Coverage Determinations
OSF HealthPlans will make coverage
determinations upon request for prior authorization requirements for
non-covered medications, to bypass step therapy requirements, or to
grant exceptions to the tiered payment requirements whenever it has
been determined that an exception is medically appropriate because the
preferred drug (or on –formulary drug in the case of a formulary
exception request): (a) would not be as effective for the enrollee as
the requested drug; or (b) would have adverse effects for the
enrollee, or (c) both.
Documentation in the medical records is
essential for approval.
- Standard determination: decisions will be
made no later than 72 hours after receipt of the request (or receipt
of the physician’s certification for exceptions process)
- Expedited determinations: decisions will be
made not later than 24 hours after receipt of the request (or the
receipt of the physician certification for exceptions request)
- Failure to meet adjudicated timeframes: will
automatically forward the enrolled request to the IRE (Center for
Health Dispute Resolution)
The physician requesting the medication coverage
determination must complete the quick authorization form and answer
the following questions:
- List the present medication the member is
utilizing
- List the new medication that is being
requested.
- List date of adverse drug reactions to the
utilized medication.
- Describe all adverse drug reactions to the
utilized medication.
- Please explain lack of effectiveness of this
medication.
- Relevant test/Laboratory data that supports
adverse reaction.
- List all other medications in this same drug
class that have been used.
- Describe all adverse drug reactions to the
medications in the drug class.
- Record how many Medicare medication coverage
determinations have you requested in the last 12 months
Coverage Determination
MedRx Part D
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