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Prescription submission and denial
• Healthcare providers (HCPs) send prescriptions to the pharmacy.
• Denials may occur due to prior authorization (PA) requirements.
• Denials can result in a 13-page denial letter with recommended next steps.
• Denials can be appealed by the HCP once all steps have been completed or by the patient once denial is mailed.
• Denial letters are mailed to the patient.
Prior authorization process
• PA can be submitted via CoverMyMeds.
• PA can be required for original brand preferred medications.
• A second PA can be drafted based on denial information.
• PA denials can be processed by the pharmacist.
• PA approvals can be received, allowing the prescription to be sent to the pharmacy.
Appeals and alternative options
• Patients can appeal denials independently.
• Alternative options can be explored, such as scheduling a doctor visit.
• Alternative options can involve requesting new patient appointments to review step alternatives.
• Alternative options can involve picking up prescriptions for alternative medications.
• Alternative options can involve submitting PA for original brand preferred medications.
Patient and insurance interactions
• Patients can receive final notifications regarding prescription approvals.
• Patients can receive rejection letters for denied prescriptions.
• Patients can switch insurance plans, affecting the prescription approval process.
• Insurance denials can be received, requiring further action.
• Insurance denials can result in notice of final adverse decisions.