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

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DocuSign Envelope ID:E8C538EF-9595-4E36-A4C9-2CA66C7BE34A as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate. 29 CFR 2560.503-1(m). An Adverse Benefit Determination also includes any rescission of coverage as defined in the regulations restricting rescissions (26 CFR 54.9815 2712T(a)(2), 29 CFR 2590.715-2712(a)(2), and 45 CFR 147.128(a)(2)), whether or not there is an adverse effect on any particular benefit at that time. The availability and contact information of an agency offering assistance to the Member with the appeals and external review processes can be found at: .healthcare.gov/using- insurance/managing/consumer-help/index.html. Redetermination(Internal Appeal) Upon initiation of a Redetermination by the Prescriber or Member (or the Member's appointed representative), additional supporting documentation may be requested by Envision from the Prescriber. Expedited Redetermination request evaluations occur as soon as possible, taking into account medical exigencies, but no later than 72 hours of receipt of the request to allow the Member to submit additional information for consideration, and standard evaluations occur within 72 hours of receipt of the request. The evaluation is performed by a clinical pharmacist or pharmacists other than the pharmacist or pharmacists that reviewed the original Coverage Determination request,to maintain impartiality within the review process. Envision will allow a Member to review the claim file and to present evidence and testimony as part of the Internal Appeals process. Envision will provide the Member, free of charge, with any new or additional evidence considered, relied upon, or generated by the Redetermination as soon as possible and sufficiently in advance of the date on which the notice of an Adverse Benefit Determination is required to be provided, to give the Member a reasonable opportunity to respond prior to that date. If the Redetermination information supports an override of an Adverse Benefit Determination, an override will be configured in the adjudication system which will allow the Claim to process. If evaluation determines the Redetermination request fails to meet the coverage criteria, the Claim will remain in rejected status. The result of the Redetermination is communicated to the Member by written letter and the Prescriber by fax. In the event the Redetermination results in an Adverse Benefit Determination, the notice to the Member and Prescriber will include information identifying the Claim, the specific reason for the Adverse Benefit Determination including a discussion of the decision including the plan provision relied upon, instructions about their right to initiate an External Review, if applicable, a statement that the Member has a right to bring a civil action under ERISA Section 502(a) following a denial upon appeal, a link providing the availability and contact information of an agency offering assistance to the Member with the external review process, if one is available, and may contain additional information as directed by Plan Sponsor. The Member may, upon request and free of charge,receive reasonable access to and copies of all documents, records, and other information used in the Coverage Determination \Pass-through PBMSA(041917) ©Envision Pharmaceutical Services,LLC Page 40 of 41