2017-528-E HR - Envision Pharmaceutical Services, LLC for pharmacy benefits

Browse Search

DocuSign Envelope ID:E8C538EF-9595-4E36-A4C9-2CA66C7BE34A EXHIBIT 1-A EnvisionRxOptions Coverage Determination and Redetermination (Internal Appeal) Program Description (Revision date 12/04/2012) Envision maintains a process for Coverage Determinations (including Clinical Prior Authorizations), and Redeterminations. Envision utilizes a claim adjudication platform to determine real-time coverage/non-coverage status for Claims submitted electronically at the Point-of-Sale. Claims failing one or more Benefit Plan coverage rules are rejected at the Point- of-Sale and information regarding the reject reason(s) is conveyed to the dispensing pharmacy at the Point-of-Sale. Pharmacy personnel may contact Envision's Customer Service Department to begin the Coverage Determination process or they may inform the Member of the reason(s) for the rejection and provide the Member with instructions to contact the Customer Service Department in the event the Member would like to initiate a Coverage Determination. Coverage Determinations (or Clinical Prior Authorizations) When a Coverage Determination request is initiated, the information connected with the rejected prescription is conveyed by Envision to the Prescriber via fax with a request for specific information regarding the Member's medication history and disease diagnosis. The Prescriber completes the form and returns it to Envision where the information provided by the Prescriber is evaluated by an Envision clinical pharmacist. Expedited Coverage Determinations occur as soon as possible, taking into account medical exigencies, but no later than 24 hours of receipt of the request and standard determinations occur within 72 hours of receipt of the request. If the information provided meets the criteria to allow an override of the initial rejection, an override will be configured in the adjudication system that will allow the Claim to process. If the clinical review determines the prescription fails to meet the coverage criteria, the prescription will remain in rejected status. The result of the Coverage Determination is communicated to the Member by written letter, the Prescriber by fax, and the dispensing pharmacy by fax. In the event the Coverage Determination results in an Adverse Benefit Determination, as defined below, the notice to the Member and Prescriber includes information identifying the Claim involved, the specific reason for the Adverse Benefit Determination, instructions about the right to initiate a Redetermination (Internal Appeal), a link providing the availability and contact information of an agency offering assistance to the Member with the appeals and external review processes, if one is available, and may contain additional information as directed by Plan Sponsor. An Adverse Benefit Determination is a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a participant's or beneficiary's eligibility to participate in a plan, and including, with respect to group health plans, a denial,reduction, or to znination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well \Pass-through PBMSA(041917) ©Envision Pharmaceutical Services,LLC Page 39 of 41