Drug exceptions time frames and member responsibilities

A member or provider may request an exception for non-covered formulary medication in lieu of a covered medication by submitting a letter of medical necessity from the prescribing provider. Information must be submitted by the provider on letterhead via a letter of medical necessity including the following: member name, failed therapies, diagnosis, and member identification number. The letter should be faxed to the attention of the Pharmacy department at 501-378-6980. Medical records may be requested to demonstrate the medical need for the excluded drug. Once all necessary information is received, a determination will be made within 15 calendar days (or within 72 hours for cases involving urgent care) and the member and provider will be notified. Expedited review requests due to exigent circumstances must be noted as such on the letter and must contain all required information, in order to be reviewed within 24 hours of this request.

If the member's request is denied, the member has the right to request an appeal. Appeal information must be submitted in writing and must include the reason the member and/or the provider disagrees with the determination and any supporting information.

Mail appeals to:
Health Advantage
Attn: Appeals Coordinator
PO Box 2181
Little Rock, AR 72203-2181

Urgent appeals may be faxed to 501-378-3366. The member and/or physician may request a clinically appropriate specialist or an external review organization to review the request. This request must be submitted in writing and may be faxed.

If the member’s request is denied on appeal, the member may have the right to an external review by an independent review organization. To obtain an external review, the member must send his/her request in writing within four (4) months of the appeal denial notice to the Arkansas Insurance Commission at the following address:

Arkansas Insurance Department
1 Commerce Way, Suite 102
Little Rock, AR 72202

Phone: 501-371-2600 or toll-free 800-282-9134
Fax: 501-371-2749
Email: insurance.consumers@arkansas.gov

The decision by the independent external reviewer will be binding on both the Plan and the member. You may be eligible for an expedited external review if the timeframe for a standard external review would seriously jeopardize the life/health of the covered person or would jeopardize the ability to regain maximum function as certified by the treating physician.

• For standard external reviews, the independent review organization will respond within 45 days after the date of its receipt of the request for the external review.
• For expedited external reviews, the independent review organization will respond within 72 hours after the date of its receipt of the request for the external review.

For more information regarding external review rights, please consult your Plan document.