its coverage determination no later than 72 hours following receipt of the request. WAC 284-43-5080(3)(b) 45 CFR A health plan that grants a standard exception request must Prescription 156.122 provide coverage of the non-formulary drug for the duration Drug Services (c)(1)(iii) of the prescription, including refills. WAC 284-43-5080(3)(b) (EHB) 45 CFR Expedited exception request. (Cont’d) 156.122 Plan must have a process for an enrollee, the enrollee's Drug (c)(2)(i) designee, or the prescriber to request an expedited review Exception/ based on exigent circumstances. WAC 284-43-5080(3)(c) 45 CFR Exigent circumstances exist when an enrollee is suffering 156.122 from a health condition that may seriously jeopardize the (c)(2)(ii) enrollee's life, health, or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a non-formulary drug. WAC 45 CFR Plan must make its determination on an expedited review 156.122 request and notify the enrollee (or designee) and prescriber (c)(2)(iii) of its determination no later than 24 hours following receipt of the request. WAC 284-43-5080(3)(c)(i) 45 CFR If exception is granted, plan must provide coverage of the 156.122 non-formulary drug for the duration of the exigency. WAC (c)(2)(iv) 284-43-5080(3)(c)(ii) 45 CFR External exception request review. 156.122 If the Plan denies a request for a standard exception or an (c)(3)(i) expedited exception, the plan must have a process for the enrollee, the enrollee's designee, or the enrollee's prescriber to request that the original exception request
Prescription Drug Services (EHB) (Cont’d) Drug Exception/ its coverage determination no later than 72 hours following receipt of the request. WAC 284-43-5080(3)(b) 45 CFR 156.122 (c)(1)(iii) A health plan that grants a standard exception request must provide coverage of the non-formulary drug for the duration of the prescription, including refills. WAC 284-43-5080(3)(b) 45 CFR 156.122 (c)(2)(i) Expedited exception request. Plan must have a process for an enrollee, the enrollee's designee, or the prescriber to request an expedited review based on exigent circumstances. WAC 284-43-5080(3)(c) 45 CFR 156.122 (c)(2)(ii) Exigent circumstances exist when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee's life, health, or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a non-formulary drug. WAC 45 CFR 156.122 (c)(2)(iii) Plan must make its determination on an expedited review request and notify the enrollee (or designee) and prescriber of its determination no later than 24 hours following receipt of the request. WAC 284-43-5080(3)(c)(i) 45 CFR 156.122 (c)(2)(iv) If exception is granted, plan must provide coverage of the non-formulary drug for the duration of the exigency. WAC 284-43-5080(3)(c)(ii) 45 CFR 156.122 (c)(3)(i) External exception request review. If the Plan denies a request for a standard exception or an expedited exception, the plan must have a process for the enrollee, the enrollee's designee, or the enrollee's prescriber to request that the original exception request
checklist-forms-2018-disability-individual-analyst-checklist.docx