156.122 no later than 24 hours following its receipt of the request, if (c)(3)(ii) the original request was an expedited exception request. Drug 45 CFR 156.122 If the plan grants an external exception review of a standard Exception/ (c)(3)(iii) exception request, the plan must provide coverage of the Substitution drug for the duration of the prescription. WAC Process (Cont’d) 45 CFR 156.122 If the plan grants an external exception review of an expedited (c)(3)(iii) exception request, the plan must provide coverage of the drug for the duration of the exigency. WAC Drug WAC Issuer must maintain a documented drug utilization review program Utilization and (5) with written procedures to assure that reviews are conducted in a Review – timely manner. Requirement WAC Nonurgent review request" any request for approval of care or to Maintain (1)(a) treatment where the request is made in advance of the patient Documented obtaining medical care or services, or a renewal of a previously Program approved request, and is not an urgent care request. Prescription Drug WAC "Urgent care review request" means any request for approval of care Drug Services Utilization or treatment where the passage of time could seriously jeopardize the (EHB) Review – life or health of the patient, seriously jeopardize the patient's ability to (Cont’d) Requirement regain maximum function or, in the opinion of a provider with to Maintain knowledge of the patient's medical condition, would subject the Documented patient to severe pain that cannot be adequately managed without Program the care or treatment that is the subject of the request. (Cont’d) (5)(A)(i) For urgent care review requests:
Drug Exception/ Substitution Process (Cont’d) 156.122 (c)(3)(ii) 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 drug for the duration of the prescription. WAC 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 drug for the duration of the exigency. WAC Drug Utilization Review – WAC and (5) Issuer must maintain a documented drug utilization review program with written procedures to assure that reviews are conducted in a timely manner. Requirement to Maintain Documented Program WAC (1)(a) Nonurgent review request" any request for approval of care or treatment where the request is made in advance of the patient obtaining medical care or services, or a renewal of a previously approved request, and is not an urgent care request. Prescription Drug Services (EHB) (Cont’d) Drug Utilization Review – Requirement to Maintain Documented Program WAC "Urgent care review request" means any request for approval of care or treatment where the passage of time could seriously jeopardize the life or health of the patient, seriously jeopardize the patient's ability to regain maximum function or, in the opinion of a provider with knowledge of the patient's medical condition, would subject the patient to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request. (Cont’d) (5)(A)(i) For urgent care review requests:
cl-forms-19-disability-sg-analyst-checklist.docx