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Exception Process / Cost Sharing / Prior Authorization Exception Process
There are three types of exceptions:
- Exceptions for coverage of non-formulary drugs
- Exceptions to utilization of management tools
- Exceptions to copayment or tiered cost sharing
Inter Valley Health Plan's formulary contains many commonly prescribed drugs. During the course of a plan member's medical care, there may be instances when a member may require a non-formulary drug or a drug that has formulary limits or restrictions (e.g., step-therapy requirements, prior authorization, or quantity limits).
Inter Valley Health Plan may approve an exception request for a non-formulary drug or a drug that has formulary limits or restrictions when medically necessary. To determine medical necessity, the Plan will verify through the physician's supporting statement(s) and/or standards documented in clinical guidelines adopted by the Plan, that 1) the patient has tried and/or has documented contraindications or intolerance to the equivalent formulary medications and 2) no other formulary agent is appropriate to treat the patient's condition. Exception requests will be processed through the Health Services Department.
In certain circumstances, a member may request a reduction in the copayment or coinsurance amount for a drug on the formulary. If a member is prescribed a drug on Tier 3, the member may request to pay the Tier 2 copayment instead of the higher Tier 3 copayment. Tier 1 (All Generics) and Tier 5 (Specialty Drugs) drugs are not eligible for cost-share reductions.
An enrollee must meet appropriate medical necessity criteria before tiered cost sharing exceptions will be approved. To determine medical necessity, the Plan will verify, through the physicians supporting statement(s) and/or standards documented in clinical guidelines adopted by the Plan, that all drugs in the lower preferred tier 1) would not be as effective for the enrollee as the requested drug, 2) would have adverse effects for the enrollee or both.
Click here to print out a copy of Inter Valley Health Plan's Exception Form.
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Cost Sharing
In some cases, members who are prescribed Tier-3 drugs may request a reduction or discount on their co-payments. The Reduction will allow members to fill Tier-3 drugs at the lower priced Tier-2 co-payments. In order to be eligible for cost sharing benefits, the provider must meet and submit the following on the member's behalf: Show proof of hardship of patient was subjected to the Tier-3 payments and Show proof of medical necessity for the Tier-3 drug or Show proof that the drug equivalent in Tiers 1 and 2 will not be as effective or The drugs in Tiers 1 and 2 would cause adverse effects and harm to the member
Cost Sharing is available for Tier-3-drugs only. back to top
Prior Authorization
Inter Valley Health Plan will process coverage determinations and exception requests in accordance with Medicare Part D regulations. Requests will be handled through the Health Services Department. Prior authorization requires a drug to be "pre-approved" in order for it to be covered under the pharmacy benefit plan.
The Pharmacy staff will adhere to the Plan approved criteria, National Pharmacy and Therapeutics clinical guidelines, and other professionally recognized standards in reviewing each case, rendering a decision based on established protocols and guidelines.
Providers can submit prior authorization request, by phone, fax, or online.
Providers will be required to submit pertinent medical/drug history, prior treatment history, and any other necessary supporting clinical information with the request.
Standard request will be reviewed and determinations will be made within 72 hours.
Expedited or urgent requests will be reviewed and determinations will be made in 24 hours. A request is considered urgent if the requestor believes that applying through the standard process may seriously jeopardize the enrollee's life, health, or ability to regain maximum function. Providers will be notified by fax or in writing of the determination.
Click here for the proper forms to initiate this request.
To initiate a request you may contact us by:
Phone: 800-523-3142
Fax: 909-623-0753
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