level of appeal rights (Maximus, ALJ, ETC)>. Your appeal decision will come in a different letter than this one. Option 1= Not Yet Decided N/A Note: Only Forward if there is a Dual Issue (Pharmacy Request/CD) Coverage While reviewing your complaint, we noticed you are Prior authorization requirement. Determination to also asking for coverage of <insert name of drug>. Otherwise educate that no Prior be filed We sent your request to a <Health Plan Name> authorization is required and give Formulary Status, unless Pharmacy Department . They will review your authorization is specifically being request and give you a response within <insert requested. number of days> days from the date we got your complaint or when it became valid, whichever is later. A standard CD request is due Your coverage decision will come in a different letter within 72 hours and an expedited than this one. is due within 24. A case must immediately be identified and forwarded by intake including a documentation note in the Option 2= Decided system . The analyst is While reviewing your complaint, we noticed you are responsible for reviewing that this also asking for coverage of <insert name of drug>. occurred upon receipt of the
level of appeal rights (Maximus, ALJ, ETC)>. Your appeal decision will come in a different letter than this one. Dual Issue (Pharmacy Request/CD) Option 1= Not Yet Decided While reviewing your complaint, we noticed you are also asking for coverage of <insert name of drug>. We sent your request to a <Health Plan Name> Pharmacy Department . They will review your request and give you a response within <insert number of days> days from the date we got your complaint or when it became valid, whichever is later. Your coverage decision will come in a different letter than this one. Option 2= Decided While reviewing your complaint, we noticed you are also asking for coverage of <insert name of drug>. N/A Coverage Determination to be filed Note: Only Forward if there is a Prior authorization requirement. Otherwise educate that no Prior authorization is required and give Formulary Status, unless authorization is specifically being requested. A standard CD request is due within 72 hours and an expedited is due within 24. A case must immediately be identified and forwarded by intake including a documentation note in the system . The analyst is responsible for reviewing that this occurred upon receipt of the