Prior Authorization

Certain drugs require prior authorization from the plan. If your physician prescribes any medication with a prior authorization requirement, he or she must contact Magellan Rx/Prime Therapeutics by calling (888) 272-1346 to receive prior authorization before you fill your prescription. In some cases you may be required to submit a letter from your physician verifying the medical necessity of the prescribed drug. After the initial approval, prior authorization may be required again periodically.

To see if your medication requires prior authorization, please refer to the Formulary. Medications that require prior authorization will be designated with “PA” in the Requirements/Limitations column.

If your request for prior authorization has been denied, you have the option to appeal.

Prior Authorization Appeal Process

The following appeal process is compliant with the State of Michigan Patient Right to Independent Review Act (PRIRA MCL 550.1951 and MCL 550.1952). If your physician has prescribed a medication quantity exceeding the University of Michigan Prescription Drug Plan guidelines, your physician may call Magellan Rx/Prime Therapeutics at (888) 272-1346 to request a “Benefit Exception Form.” If your physician prescribes a drug that was not dispensed or was denied prior authorization, you may contact Magellan Rx/Prime Therapeutics about an appeal at (888) 272-1346. If your physician has prescribed a medication that is specifically excluded from coverage in the University of Michigan Prescription Drug Plan and you want to appeal the decision, you may contact Magellan Rx/Prime Therapeutics at (888) 272-1346 for a written notice of right to appeal.

Appeal Process Timeline
Here's a brief timeline of the appeal process:

Reconsideration: Occurs within 90 days (if not requested as an appeal, Magellan Rx/Prime Therapeutics will automatically review as a reconsideration) of the date of the initial prior authorization denial

First-level appeal: Occurs within 180 days of the date of the initial prior authorization denial

Second-level appeal: Occurs within 180 days of the date of the initial prior authorization denial

Third-level independent review organization (third-party resource): Occurs within 120 days of the date of the final internal appeal determination

State review: Occurs within 60 days of the date of the third-level appeal denial

For a more comprehensive explanation of the appeal process, continue reading.
Appeal Process First- and Second-Level Prior Authorization or Benefit Exception

The first- and second-level appeal determines if the requested use meets the university’s plan design, formulary, limitations, and the standard indications, such as Food and Drug Administration and manufacturer recommendations.

If you want to appeal a prescription drug prior authorization denial or a benefit exception denial, follow the instructions in the denial letter. You may also call Magellan Rx/Prime Therapeutics at (888) 272-1346 to request a copy of the first-level appeal form.

You may authorize in writing any person, such as your physician, attorney, parent, or spouse, to represent you in the appeal process. You or your authorized representative must complete and sign the appeal form allowing Magellan Rx/Prime Therapeutics to disclose Protected Health Information necessary for the appeal. (MCL 550.1907(c))

Your first- and second-level appeals will be reviewed by Magellan Rx/Prime Therapeutics health care professionals. The first- and second-level appeals will each be completed within 15 days. When an appeal involves a medical condition for which the timeframe for completion of the appeal would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function, an “urgent appeal” can be requested. This urgent appeal can be completed within 72 hours. The written notice of appeal determination will be mailed to you and your physician.

If your second-level appeal is denied, you have 180 days from the issue date of the original denial to submit a third-level appeal based on "medical necessity."

If you have an existing prescription for a medication covered by the plan (not a new prescription), the university will provide you a 30-day override for your medication until your appeal is reviewed. To obtain a continuation override during the appeal process, call the SSC Contact Center at 5-2000 from the Ann Arbor campus, (734) 615-2000 locally, or (866) 647-7657 toll-free for off-campus long-distance calls within the U.S., to speak with a representative Monday–Friday, 8 a.m.–5 p.m.
Appeal Process Third Level – Medical Necessity

If a second-level appeal has been denied for your medication, you or your authorized representative may call Magellan Rx/Prime Therapeutics at (888) 272-1346 to request an independent external review.

A third-level appeal is reviewed by an independent specialist physician outside of Magellan Rx/Prime Therapeutics. This includes a review of any medical records provided, a review of the medical literature, and discussion of the medical necessity request with your physician. Medical necessity means that there is solid, credible evidence for the use of the drug as requested for your condition.

The third-level appeal review will be completed within 15 days. If you have a medical condition where the timeframe for completion of an expedited grievance would seriously jeopardize your life or health or your ability to regain maximum function, as substantiated by a physician either orally or in writing, you or your representative may file a request for an expedited external review by the Office of General Counsel – Health Care Appeals Section, Michigan Department of Insurance and Financial Services (DIFS) at the same time as you file a request for an expedited third-level appeal for medical necessity. You and your physician will receive a written rationale in support of the final decision.

If the third-level appeal is denied, you or your authorized representative have 60 days from the date you received the final determination to request a State of Michigan External Claim Review (Appeal Process Fourth Level).
Appeal Process Fourth Level – State of Michigan External Claim Review
With respect to any healthcare benefits insured by a company subject to the insurance laws and regulations of the state of Michigan, if you disagree with the prescription drug plan’s final decision following whatever required or voluntary levels of appeal are available, or your request for review at the first or second level has not been completed within the timeframe above, you may request an external review from the Office of General Counsel – Health Care Appeals Section, Michigan Department of Insurance and Financial Services (DIFS). Once you have exhausted the internal appeal procedures described above, you or your authorized representative have the right to request an external review from DIFS. DIFS’s decision is the final administrative remedy under Michigan’s Patient’s Right to Independent Review Act (PRIRA). This external review procedure is voluntary, and you are not required to seek to have your claim reviewed through this procedure.

Within 60 days of the date you either received a final determination on appeal, or should have received it, you or your authorized representative may send a written request for an external review to DIFS. Mail your request, including the required forms that may be obtained from the DIFS Claims Administrator, to:

Office of General Counsel
Health Care Appeals Section
Michigan Department of Insurance and Financial Services (DIFS)
P.O. Box 30220
Lansing, MI 48909-7720
(877) 999-6442

These items may be requested for consideration in the external claim review:

Your pertinent medical records

The attending healthcare professional's recommendation

Consulting reports from appropriate healthcare professionals and other documents submitted by the prescription drug plan, you, your authorized representative, or your treating provider

The terms of coverage under your prescription drug plan

The most appropriate practice guidelines, which may include generally accepted practice guidelines, evidence-based practice guidelines, or any other practice guidelines developed by the federal government or national or professional medical societies, boards and associations

Any applicable clinical review criteria developed and used by the prescription drug plan or its designee utilization review organization.

If your request is not accepted for external review because the request is not complete, DIFS shall inform you and, if applicable, your authorized representative what information or materials are needed to make the request complete. If a request is not accepted for external review, the commissioner shall provide written notice to you and, if applicable, your authorized representative, and the prescription drug plan of the reasons for its non-acceptance.

If your request for external review involves an issue of medical necessity or clinical review criteria, and is otherwise found to be appropriate for external review (a decision to be made by DIFS), DIFS will send your claim to an independent organization to conduct an external review (“IRO”), consisting of independent clinical peer reviewers. After DIFS has decided to accept your case for external review, you will have an opportunity to provide additional material to DIFS within 7 days after your request is accepted. The insurance carrier must give documents and information that it considered in making its final determination to the IRO within 7 business days after it receives notice of your request to the commissioner. The IRO will recommend, within 14 days, whether DIFS should uphold or reverse the insurance carrier’s determination of your claim. DIFS must then decide within 7 business days whether or not to accept the IRO’s recommendation and will notify you of its decision.

Not later than 5 business days after the date of receipt of a request for an external review, DIFS shall complete a preliminary review of the request to determine all of the following (MCL 550.1911(2)):

Whether you were a covered person in the prescription drug plan at the time the prescription was requested or, in the case of a retrospective review, were a covered person in the prescription drug plan at the time the prescription was provided.

Whether the prescription that is the subject of the adverse determination or final adverse determination reasonably appears to be a covered service under your prescription drug plan.

Whether you have exhausted the health carrier's internal grievance process unless you are not required to exhaust the health carrier's internal grievance process.

You have provided all the information and forms required by the commissioner that are necessary to process an external review, including the health information release form.

Whether the prescription that is the subject of the adverse determination or final adverse determination appears to involve issues of medical necessity or clinical review criteria.

If your request for external review does not appear to involve issues of medical necessity or clinical review criteria, and is otherwise found to be appropriate for review, DIFS’s staff may conduct the external review or DIFS may assign an independent organization (IRO) to conduct the external review. The reviewer will then recommend whether DIFS should uphold or reverse the prescription drug plan’s determination. DIFS will notify you of the decision, and that decision is your final administrative remedy.

You or your authorized representative may make a request for an expedited external review with DIFS within 10 days after you receive an adverse determination if:

The adverse determination involves a medical condition for which the timeframe for completion of an expedited internal grievance would seriously jeopardize your life or health, or would jeopardize your ability to regain maximum function as substantiated by a physician either orally or in writing

You or your authorized representative has filed a request for an expedited internal grievance

An expedited external review shall not be provided for retrospective adverse determinations or retrospective final adverse determinations.

Contact the Claims Administrator at (877) 999-6442) to find out what you are required to do to receive a review:

Office of General Counsel
Health Care Appeals Section
Michigan Department of Insurance and Financial Services (DIFS)
P.O. Box 30220
Lansing, MI 48909-7720

Immediately after receiving your request for an expedited review, the DIFS will decide if your claim is appropriate for external review and assign it to an IRO. If the IRO decides that you do not have to first complete the expedited internal review procedure, it will review your request and make its recommendation to the DIFS within 36 hours. The DIFS must then decide within 24 hours whether or not to accept the recommendation of the IRO. The DIFS’s decision is the final administrative remedy under Michigan’s Patient’s Right to an Independent Review Act (PRIRA).

An external review decision and an expedited external review decision are the final administrative remedies available under this act. A person aggrieved by an external review decision or an expedited external review decision may seek judicial review no later than 60 days from the date of the decision in the circuit court for the county where they reside or in the circuit court of Ingham County. You may also seek other remedies available under applicable federal or state law.

You or your authorized representative may not file a subsequent request for external review involving the same adverse determination or final adverse determination for which you have already received an external review decision.

Questions About Your Benefits?

Submit your questions to the SSC Contact Center. You can also call the SSC at 5-2000 from the Ann Arbor campus, (734) 615-2000 locally, or (866) 647-7657 toll free, Monday through Friday from 8 a.m. to 1 p.m. and 2 p.m. to 5 p.m..

Limitations

The University of Michigan in its sole discretion may modify, amend, or terminate the benefits provided with respect to any individual receiving benefits, including active employees, retirees, and their dependents. Although the university has elected to provide these benefits this year, no individual has a vested right to any of the benefits provided. Nothing in these materials gives any individual the right to continued benefits beyond the time the university modifies, amends, or terminates the benefit. Anyone seeking or accepting any of the benefits provided will be deemed to have accepted the terms of the benefits programs and the university's right to modify, amend, or terminate them. Every effort has been made to ensure the accuracy of the benefits information in this site. However, if any provision on the benefits plans is unclear or ambiguous, the Benefits Office reserves the right to interpret the plan and resolve the problem. If any inconsistency exists between this site and the written plans or contracts, the actual provisions of each benefit plan will govern.

Prior Authorization

Prior Authorization Appeal Process

Questions About Your Benefits?

Limitations

Benefits Office

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