Samaritan Select

Medication exception process

For this policy the term "beneficiary" or "member" shall mean the actual member or a member's authorized representative or the member's prescribing physician acting on behalf of the member.

If it is medically necessary for a beneficiary to have medication that is not on the Approved Medication List, the medical exception process will need to be followed as outlined below:

1. The beneficiary's physician will fill out a medication exception form and fax it to the plan for review along with any documentation necessary that speaks to the need of the non-covered medication over an Approved medication choice.
2. Upon receipt of this information the plan's medical reviewer will review the information presented and either ask for additional information or make a determination.
3. If the medical reviewer asks for additional information from the physician, the medical reviewer upon arrival at the plan will review the information and a determination will be made.
4. If an approval is given for the non-covered medication a prior authorization will be placed into the claims payment system for a period of time specified by the reviewer. The requesting physician will be notified of the approval.
5. If a denial is given for the non-covered medication a notice of denial will go to the physician. Within five-business days a denial letter will be sent to the beneficiary and a copy will be sent to the requesting physician. In this notice of denial the reconsideration and appeal information will be given.
6. If the request is denied, it is expected that the beneficiary's PCP would be switched to a Samaritan Select Approved medication.

After a request is submitted to the plan a request for additional information or a determination will be sent to the physician within three business days.

Purpose: This policy will discuss the procedures Samaritan Select Staff will take in processing appeals in compliance with a beneficiaries rights, medical criteria and state and federal regulations.

Beneficiaries receive information about their right to file an appeal including the right to expedited review at the following times:

• Upon initial enrollment
• Upon notification of an adverse organization determination
• Upon notification of the result of a denied Medication Exception

Process:

When a beneficiary contacts the plan verbally or in writing with a complaint Customer Service Staff must assess the complaint and determine whether to file it as a grievance or an appeal. Customer Service Staff will date stamp written appeals and send to pharmacy department. Expedited Appeals are handed to the Pharmacy Staff immediately upon receipt.

If the beneficiary had the intention of filing an appeal that was misclassified and it is actually a grievance Customer Service Staff will send the beneficiary a letter informing them that the complaint has been forwarded to the grievance process.

Standard Requests for Reconsideration:

A beneficiary requests reconsideration from Samaritan Select after receiving an adverse organization decision.

• Telephone requests: If the request is received verbally via telephone, Customer Service Staff will direct the beneficiary to the Pharmacy Staff. The Pharmacy Staff will document the request in the beneficiary's own words in THE SYSTEM and will repeat the request back to the beneficiary to confirm the accuracy and will tell the beneficiary that if they want to submit any evidence to send it to our address. Pharmacy Staff will also send the appeals acknowledgment letter with the form to the beneficiary for them to sign and send back to Samaritan Select granting Samaritan Select permission to move forward on the request.
• Written requests: If the request for reconsideration is in a written format, Customer Service will date stamp the request and put it in the "Pharmacy Appeals In Box" located at the processing center, unless it is an expedited request in which case the Customer Service Staff gives the appeal directly to the Pharmacy Staff immediately upon receipt. The "Pharmacy Appeals In Box" is to be emptied by the end of the day by the Samaritan Select Pharmacy Staff.

Once the plan has received the appeal either verbally or in writing and the above actions have been taken and the acknowledgment letter has been received, if applicable, Samaritan Select Pharmacy Staff will send the beneficiary a response letter. The letter will inform the beneficiary that Samaritan Select has seven days from the date of the request to make a determination on the request.

The plan's medical director and pharmacist review all appeals. Additional information (i.e., medical records) may be requested to make a decision.

Expedited Requests for Reconsideration:

A beneficiary requests an expedited review from Samaritan Select after receiving an adverse coverage determination (medical exception) either verbally or in writing.

If the beneficiary's physician is requesting the expedition for reconsideration the Samaritan Select Pharmacy Staff will send an acknowledgement letter to the physician. The request can be submitted either orally or in writing with supporting documentation indicating that applying the standard time frame could seriously jeopardize the life or health of the beneficiary or the beneficiary's ability to regain maximum function. Samaritan Select will move forward with the expedited request and have contacted the beneficiary and their provider within 72 hours of the request of the decision of the reconsideration verbally and will follow up in writing within 3 days of the verbal communication.

If the request for an expedited review for reconsideration comes from a beneficiary Samaritan Select Pharmacy Staff will make a determination immediately upon receipt of whether or not to expedite based on the following criteria.

• Namely: Would applying the standard time frame seriously jeopardize the beneficiary's life or health or his/her ability to regain maximum function?

Expedition Approved:

If the request for an expedited review is approved either through a provider request or through a beneficiary request the case is given to the medical director. The medical director will review all past materials in lieu of all new materials and make a determination from the initial request for expedited appeal.

The case is then given back to the Pharmacy Staff to notify the beneficiary and the provider of the determination, which is done within 72 hours of the initial request for expedited review. The determination is also sent to the beneficiary in writing (not more than 3 days after the verbal communication).

If the decision is to overturn the initial adverse coverage determination the Samaritan Select Pharmacy Staff will send the beneficiary a letter informing them of the decision, will input the information into the system and will update and document the system and the case file. All materials are filed in the case file.

If the decision is to uphold the initial coverage determination a letter is sent to the beneficiary.

Expedition Denied:

If the determination is to deny the request for an expedited appeal Samaritan Select Pharmacy Staff sends the beneficiary a letter informing them that the request has been denied and that the case will be reviewed following the standard reconsideration process, which will be determined in no more than 7 days from the date of the request. The letter will also outline their right to file an expedited grievance.

The Samaritan Select Pharmacy Staff document the system and the case file and begins the Standard Appeals process.

Non-Covered Medication Process:

If the beneficiary is taking non-covered medications:

1. The pharmacy department will place a temporary authorization will be placed in the claims system for a time period of 30 days.
2. The pharmacy department will send notice to beneficiary's physician explaining the medical exception process.
3. This will give the physician the opportunity to change the medication to an Approved medication or to start the medication exception process if it is medically necessary for this beneficiary to receive a non-covered medication.
4. If the plan has not received any information from the physician after the beneficiary has been on the plan for 30 days the notice will be resent.
5. If the plan has not received any information two weeks before the original prior authorization is to expire, a staff member will notify the plan's medical director of physician's non-compliance so that further corrective action can be taken.
6. The authorization will be extended in 30-day increments.
7. If the plan has received no contact from the physician's office within 30-days from the Medical Director's involvement the beneficiary's case will be brought before the P&T Committee for review and corrective action plan.

Pharmacy Initiated Non-Covered Medication:

If the plan is unable obtain a list of non-covered medication from the beneficiary, the beneficiary may try to fill these prescriptions a their pharmacy. If the plan receives a call from a pharmacy regarding a member that has just enrolled in the plan the non-covered medication process will be put into place. See medication exception process for continued process.