A coverage decision is a decision we make about your benefits and coverage. This includes prior authorization requests or exception requests for drugs that are not on the formulary or are on the formulary but have a quantity limit or step therapy.
If we make a coverage decision and you are not satisfied with the decision, you can “appeal” this decision. An appeal is a formal way of asking us to review and change an adverse coverage decision we have made.
When you appeal a decision the first time, this is called a Level 1 appeal. In this appeal, we review the coverage decision we made to check to see if we applied the coverage rules properly. Your appeal is handled by a different reviewer than the one who made the original unfavorable decision. When we complete the review, we will give you our decision.
If we say no to the Level 1 appeal, you can ask for a Level 2 appeal which is conducted by an Independent Review Organization that is not connected to us. If you are not satisfied with the decision at the Level 2 Appeal, you are able to bring a civil action under section 502(a) of ERISA following an Adverse Benefit Determination on review. (Note: refer to your Summary Plan Document(SPD) for more information regarding your various appeal levels, some plans offer more than two appeal levels)
You may request a coverage decision the following ways:
You or your prescriber may request an appeal up to 180 days after we issue an adverse (denied) coverage decision.
Mail: WithMe Health
ATTN: Member Services
400 S El Camino Real Suite 1150
San Mateo, CA 94402
Below you'll find various prior authorization/exception forms for your prescriber to complete.
State Specific Prior Authorization Forms
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