As a member of American Health Advantage of Oklahoma, you may be taking medications that are not currently on our formulary. However, you may be entitled to a temporary supply of your prescription to help you transition into our plan. This transition period will allow you time to consult with your doctor to identify another suitable medication or request a coverage exception for your non-formulary drug.
For more information on our transition policy, click here.
Medication Therapy Management Program
Medication Therapy Management (MTM) is a program that helps ensure that your medications are effective, identify any side effects, uncover any interactions between medications you are taking, and offer guidance on problems that may be occurring as well as offering a plan to lower your costs if possible.
As a member of American Health Advantage of Oklahoma and through our MTM program, you have access to a comprehensive medication review through a one-on-one consultation with a pharmacist or other qualified medical professional. You will receive a written summary of the consultation including a medication action plan as well as a personal medication list. This service is free of charge to our members.
Please see the link below for more information on our Medication Therapy Management program.
Medication Therapy Management
Coverage Determinations and Redeterminations
A coverage determination is any decision made by American Health Advantage of Oklahoma regarding:
- A Formulary Exception
- A Tiering Exception
- Member disagrees with the plan’s cost sharing requirements.
- Member disagrees with quantity limits or dosage restrictions on medications
- Member disagrees with the plan’s step therapy requirements
- Prior Authorization and other utilization management requirements
- Receipt of or payment for a prescription drug that a member has previously paid for and believes may be covered
How to Request a Coverage Determination
A member, a member’s prescriber or a member’s representative may request a standard or expedited coverage determination by filing a request with American Health Advantage of Oklahoma orally or in writing.
How American Health Advantage of Oklahoma Processes Coverage Determination Requests
Decisions for expedited coverage determination requests that do not include exceptions will be made within 24 hours or within 72 for standard requests.
For exception requests, the adjudication time frames do not begin until the enrollee’s prescriber submits his or her supporting statement to American Health Advantage of Oklahoma.
For ALL payment requests, American Health Advantage of Oklahoma will provide decisions within 14 calendar days.
If our coverage determination is unfavorable, the notice will contain the information needed to file a request for redetermination.
Written redetermination requests may be made by using the Coverage Redetermination Request Form.
To request coverage redetermination online, click the following link: Online Redetermination Request.