Drug 45 CFR 156.122 Plan must make its determination on an expedited review request Exception (c)(2)(iii) and notify the enrollee (or designee) and prescriber of its Process determination no later than 24 hours following receipt of the request. (Cont’d) WAC 284-43-5080(3)(c)(i) 45 CFR 156.122 If exception is granted, plan must provide coverage of the (c)(2)(iv) drug for the duration of the exigency. WAC 45 CFR 156.122 External exception request review. (c)(3)(i) 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 and subsequent denial of such request be reviewed by an independent review organization. WAC 45 CFR 156.122 Plan must make its determination on the external exception request (c)(3)(ii) and notify the enrollee (or designee) and the prescriber of its determination no later than: WAC 284-43-5080(6)(a) 72 hours following its receipt of the request, if the original request was a standard exception request, and no later than 24 hours following its receipt of the request, if the original request was an expedited exception request. 45 CFR 156.122 If the plan grants an external exception review of a standard exception (c)(3)(iii) request, the plan must provide coverage of the non-formulary drug for the duration of the prescription. WAC 284-43-5080(6)(b) 45 CFR 156.122 If the plan grants an external exception review of an expedited exception (c)(3)(iii) request, the plan must provide coverage of the non-formulary drug for the duration of the exigency. WAC 284-43-5080(6)(b)
Drug Exception Process (Cont’d) 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 drug for the duration of the exigency. WAC 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 and subsequent denial of such request be reviewed by an independent review organization. WAC 45 CFR 156.122 (c)(3)(ii) Plan must make its determination on the external exception request and notify the enrollee (or designee) and the prescriber of its determination no later than: WAC 284-43-5080(6)(a) 72 hours following its receipt of the request, if the original request was a standard exception request, and no later than 24 hours following its receipt of the request, if the original request was an expedited exception request. 45 CFR 156.122 (c)(3)(iii) If the plan grants an external exception review of a standard exception request, the plan must provide coverage of the non-formulary drug for the duration of the prescription. WAC 284-43-5080(6)(b) 45 CFR 156.122 (c)(3)(iii) If the plan grants an external exception review of an expedited exception request, the plan must provide coverage of the non-formulary drug for the duration of the exigency. WAC 284-43-5080(6)(b)
cl-forms-19-hmo-ind-analyst-checklist.docx