An unfavorable decision may occur after the review of a prior authorization, step therapy override, formulary exception, coverage exception, or quantity limit exception. If you disagree with the decision that is made, you or your authorized representative can appeal this decision within 180 calendar days of the denial notice. Some states may allow your doctor to file an appeal on your behalf in certain circumstances. An appeal is a request to reconsider an unfavorable decision made regarding a product or service (i.e. denial of coverage of a prescription drug). You, your doctor, or your authorized representative may ask for an urgent or standard appeal.
What if my situation is urgent?
If your situation meets the legal definition of urgent, your review will be expedited. Generally, an urgent situation is one in which your health may be in serious jeopardy or, in the opinion of your doctor, you may experience pain that cannot be adequately controlled while waiting for your appeal decision. For urgent requests, RxAdvance has up to seventy-two (72) hours from the time of receipt to respond with a decision. Call the number on the back of your Member ID Card for any urgent requests.
How long does the appeals process take?
For non-urgent appeals, RxAdvance has up to thirty (30) days from the date of receipt to respond with a decision.
What if I need help understanding this appeals process?
Additional information regarding your appeals rights is included with the decision letter. If you need assistance understanding your appeals rights, please contact RxAdvance by calling the phone number on the back of your Member ID Card.
For your convenience, an appeals form is available here.
Please send your appeal to the following address:
Attn: Clinical Appeals
136 Turnpike Road,
Southborough, MA 01772
Fax: 508-452-0096 (for standard appeals requests)
508-452-6421 (for urgent appeals requests)
Please include your name, address, Member ID, reasons for appeal, and any supporting documentation you wish to attach. You may send in medical records, doctors’ letters, or any other information relevant to your appeal. Ask your doctor to provide you with any relevant documentation. For formulary exception requests, your doctor must provide a statement supporting coverage of this prescription drug.
External Review: If you have used all of your internal appeals rights, you may have the right to request an external review by an independent health care professional who has no association with RxAdvance. To exercise your right to an external review, you or your authorized representative must submit the external review request within four (4) months of receipt of the appeals denial notice. For standard external reviews, a decision will be made within 45 days of receiving your request. If you have an urgent situation where your health may be in serious jeopardy or, in the opinion of your doctor, you may experience pain that cannot be adequately controlled while waiting for your review decision you may be entitled to request an expedited external review of our denial.
RxAdvance does not provide reimbursements, bonuses, or incentives of any kind to staff or health care providers based on consumer utilization of any health care product or service. RxAdvance prohibits the use of financial incentives based directly on consumer utilization of services. RxAdvance strives to maintain the highest level of objectivity when making utilization management decisions.