Prescription Drug Benefit

A coverage determination is decision made by our plan (not the pharmacy) about your prescription drug benefits, including whether a particular drug is covered, whether you have met all the requirements for getting a requested drug, how much you’re required to pay for a drug, and whether to make an exception to a plan rule when you request it.

If a drug is not covered on our plan, you can ask American Health Advantage of Oklahoma to make an “exception.” An exception is a type of coverage decision. Similar to other types of coverage decisions, if American Health Advantage of Oklahoma turns down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. American Health Advantage of Oklahoma will then consider your request.

A coverage determination may be requested by any of the following:

• You or your representative may request a coverage determination.
• Your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) can request a coverage determination for you on your behalf.

A coverage determination may be requested for any of the following:

• Covering a Part D drug for you that is not on American Health Advantage of Oklahoma’s List of Covered Drugs (Formulary).
  • You may ask American Health Advantage of Oklahoma for an exception if you or your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) believes you need a drug that isn’t on your American Health Advantage of Oklahoma’s List of Covered Drugs (Formulary).
  • You may ask for an exception if your network pharmacy can’t fill a prescription as written.
• Removing a restriction on American Health Advantage of Oklahoma’s coverage for a covered drug.
  • You may ask for an exception if you or your prescriber believe that a coverage rule (such as a prior authorization) should be waived.
• Changing coverage of a drug to a lower cost-sharing tier. (Tier Exception).
  • You may ask for an exception if you think you should pay less for a higher tier drug because you or your prescriber believe you can’t take any of the lower tier drugs for the same condition. Applies if your plan has multiple tiers for your Part D Drugs.
• Request for payment.
  • You may ask us to pay for a prescription that you already paid for.

Your doctor or other prescriber must give American Health Advantage of Oklahoma a written statement that explains the medical reasons for requesting an exception. For a faster decision, include medical information from your doctor or other prescriber when you ask for the exception.

American Health Advantage of Oklahoma can accept or deny your request.

If American Health Advantage of Oklahoma approves your request for an exception, our approval usually is valid until the end of the plan year. This is true if your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.

If American Health Advantage of Oklahoma says no to your request for an exception, you can ask for a review of American Health Advantage of Oklahoma’s decision by making an appeal. If your health requires a quick response, you must ask American Health Advantage of Oklahoma to make a “fast decision”.

A redetermination is also known as an appeal. If American Health Advantage of Oklahoma denies a member’s coverage determination/exception, the member may appeal the decision to American Health Advantage of Oklahoma by requesting a redetermination.

What Is a Grievance?

A grievance is a type of complaint that does not involve payment or denial of services by American Health Advantage of Oklahoma or a Contracting Medical Provider. For example, you would file a grievance if:

• You have a problem with things such as the quality of your care during a hospital stay;
• You feel you are being encouraged to leave your plan;
• Waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room;
• Waiting too long for prescriptions to be filled;
• The way your doctors, network pharmacists or others behave;
• Not being able to reach someone by phone or obtain the information you need; or
• Lack of cleanliness or the condition of the office.

Who Can File a Grievance?

A grievance may be filed by any of the following:

• You may file a grievance.
• Your authorized representative.

Why File a Grievance?

You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with American Health Advantage of Oklahoma or a Network Participating Provider or Pharmacy, especially if such complaints result from misinformation, misunderstanding, or lack of information.

Can I Expedite a Grievance?

Yes. If you disagree with American Health Advantage of Oklahoma’s decision to extend the timeframe on your organization determination or reconsideration, or American Health Advantage of Oklahoma’s decision to process your expedited request as a standard request. In such cases, you may file an expedited grievance and receive a response within twenty-four (24) hours of receipt.

Where can a Grievance Be Filed?

You may file a standard grievance in writing directly to: American Health Advantage of Oklahoma Appeals and Grievances Department, 201 Jordan Road, Suite 200, Franklin, TN 37067 by faxing 1-844-280-5360 or over the phone by contacting our Member Services Department at our toll-free number at 1-866-583-4649; TTY 1-833-312-0046. Our hours are between 8:00 a.m.– 8:00 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

If you would like you can file a complaint directly to Medicare by filling out the complaint form at https://www.medicare.gov/MedicareComplaintForm/home.aspx.

Quality Measurement & Performance Improvement:

• Continuous improvement and monitoring of medical care, patient safety, and delivery of services
• Data analysis and standard reporting is used in the Annual Quality Improvement Work Plan

Measurable Goals and Health Outcomes for the Model of Care

• Processes and procedures to determine health outcomes are met

Member Satisfaction:

• Assessed annually

Model of Care Evaluation:

• Data is collected, analyzed and evaluated on a monthly, quarterly, and annual basis from each Model of Care domain to monitor performance, identify areas for improvement, and to ensure program goals have been meet

Dissemination of SNP Quality Performance Results

• Results shared within the organization and provider network