Coverage Decisions & Appeals

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 call our Med Guide Team
• Your prescriber can fax a completed prior authorization/exception form to us
• Your or prescriber can mail WithMe Health the completed prior authorization/exception form

You or your prescriber may request an appeal up to 180 days after we issue an adverse (denied) coverage decision.

• Standard appeal requests, which are reviewed and decided in 30 calendar days of receipt of the request, must be submitted in writing by fax or mail.
• Expedited appeal requests, which are reviewed and decided within 72 hours of receipt of the request, may be submitted in writing or over the phone.

Contact Information:

Mail: WithMe Health
ATTN: Member Services
P.O. Box 1446
Hudson, OH 44236
Fax: 1-866-678-8301
Phone: 1-866-840-1877

Below you'll find various prior authorization/exception forms for your prescriber to complete. You or your prescriber may also begin the coverage decision process through our online portal.

• General Prior Authorization Request Form
• Cystic Fibrosis PA Form
• Descovy/Truvada PA Form
• Erectile Dysfunction PA Form
• Hemophilia PA Form
• Hepatitis C PA Form
• Long Acting Opioids PA Form
• Praulent_Repatha Form PA Form
  
• RA/Crohn's/Psoriasis PA Form
  
• Weight Loss PA Form
• Non-Formulary Exception
  
• Quantity Limit Exception
• Step Therapy Exception

State Specific Prior Authorization Forms

• State of California Prior Authorization Form
• State of Colorado Prior Authorization Form
• State of Illinois Prior Authorization Form
• State of Iowa Prior Authorization Form
• State of Louisiana Prior Authorization Form
• State of Massachusetts Prior Authorization Form
  
• State of Oregon Prior Authorization Form
• State of Texas Prior Authorization Form