EMI Health Explanation of Exceptions, Grievances & Appeals
Process for Exception to Formulary
You or your appointed representative may request a formulary exception by writing to:
Please include your name and member ID number, the doctor’s name and telephone number, the name of the medication, and any information relevant to your request. If you require an urgent or fast review, please notify Express Scripts at 1-800-753-2851, or TTY/TDD should call toll-free 1-800-716-3231. Please note that not all appeal requests are eligible for the urgent review process. Urgent appeals will be decided within 24 hours.
Coverage Limits and Appeals
Some of the drugs covered by your EMI Health Plan have coverage limits. For example, prescription drugs used for cosmetic reasons may not be covered without your doctor’s approval. In addition, some medications might be limited to a certain number of pills or a total dosage within a period of time.
If you have a prescription for a drug with a coverage limit, your pharmacist will tell you that approval is needed before the prescription can be filled. The pharmacist will also give you a toll-free number to call.
If you are told there is a coverage limit, more information may be needed to see if your prescription meets the plan’s coverage conditions. We will notify you and your doctor of the decision in writing. If coverage is approved, the letter will indicate the amount of time allowed under your coverage. If coverage is denied, the letter will provide an explanation and information on how to submit an appeal.
Some examples of drugs requiring Prior Authorization: Human growth hormone, Multiple Sclerosis Therapy, Immunosuppressants, Forteo, Oxycontin, Regranex, Proton Pump Inhibitors.
Example of drug with quantity limits: Zocor - 30 tablets for 30 days or 90 tablets for 90 days.
Medication Therapy Management Program
EMI Health offers a medication therapy management program for members who have multiple medical conditions, who are taking many prescription drugs, and who have high drug costs. This program was developed for EMI Health by a team of pharmacists and doctors. We use this medication therapy management program to help us provide better care for our members. For example, this program helps us to make sure that our members are using appropriate drugs to treat their medical conditions and help to identify possible medication errors.
EMI Health offers the following medication therapy management services:
Eligibility: The medication therapy management program is available to beneficiaries who meet the following criteria:
Notification: EMI Health will mail a letter to beneficiaries who qualify explaining the medication therapy management program and inviting them to call and speak with a pharmacist for counseling. A toll-free number will be provided in the letter.
Counseling and Education Services: Those beneficiaries that accept the invitation for medication therapy management services will have access to our in-house pharmacists specially trained in patient counseling. Counseling and education services are designed to meet a patient’s unique needs and may include conversations regarding medication compliance, drug education, and health and safety issues.
To learn more about our medication therapy management program, contact Member Service toll-free at 1-800-758-3605, 24 hours a day, 7 days a week. TTY/TDD should call toll-free 1-800-716-3231, 24 hours a day, 7 days a week. Please note that Member Service is not available on Thanksgiving and Christmas.
The name of the Express Scripts's service grievance procedure is called Express Scripts Complaints and Grievances.
Express Scripts Complaints and Grievances addresses concerns about the service you have received. For example, you may file a service grievance if you are dissatisfied about the way a staff person has handled your particular issue, or with the care you received from your pharmacy. Please note that if you have a concern about a medication that is not covered or a coverage decision you should file an Appeal (Express Scripts Benefit Coverage Request).
You may file a service grievance by calling Express Scripts Customer Service (see number on back of your card) or by completing and submitting the Express Scripts Service Complaint and Grievance form located at: www.express-scripts.com .
Express Scripts will contact you by phone to resolve your service grievance. If your service grievance is not resolved in 5 days, you will receive a written acknowledgement that your grievance has been received. Expect your service grievance to be resolved within 30 days. After the service grievance is resolved, you will receive a written resolution confirmation. In the rare instance that your grievance is not resolved in 30 days, Express Scripts may request a 14 day extension from Medicare.
All Appeal, Redetermination, and Expedited Review Processes
You ask us to pay for a prescription drug you have already received; this is a request for an “initial decision” about payment. To request this type of review, you can call us at 1-800-413-1328, or TTY/TDD should call toll-free 1-800-716-3231, or write us at:
Please include your name and member ID number, the doctor’s name and telephone number, the name of the medication, and any information relevant to your request.
You ask for a Part D drug that is not on your plan's list of covered drugs (called a "formulary"); this is a request for a "formulary exception." A "formulary exception" is a type of "initial decision." You can call us at 1-800-753-2851, or TTY/TDD should call toll-free 1-800-716-3231, to ask for this type of decision.
You ask for an exception to our plan’s utilization management techniques. These are also considered to be requests for “formulary exceptions,” and are a type of “initial decision.” You can call us at 1-800-753-2851, or TTY/TDD should call toll-free 1-800-716-3231, to ask for this type of decision.
You ask for a non-preferred Part D drug at the preferred cost level; this is a request for a "tiering exception." A "tiering exception" is a type of "initial decision." You can call us at 1-800-841-5409, or TTY/TDD should call toll-free 1-800-716-3231, to ask for this type of review.
You ask that we reimburse you for a purchase you made from an out-of-network pharmacy. In certain circumstances, out-of-network purchases, including drugs provided to you in a physician’s office, will be covered by the plan. You should submit your claim using the Out of Network Direct Claim Form to request payment or coverage for drugs provided by an out-of-network pharmacy or in a physician’s office.
If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. This statement must be sent to us with any requests for coverage decisions sent directly by your appointed representative.
You also have the right to have an attorney ask for an initial decision on your behalf. You can contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify.
Asking for a fast decision: You, your doctor, or your appointed representative can ask us to give a “fast” decision (rather than a “standard” decision) by calling us at: 1-800-753-2851 or TTY/TDD should call toll-free 1-800-716-3231. Or, you can deliver a written request to
Fax it to:1-888-235-8551 Express Scripts’s normal business hours are from 8 a.m. to 9 p.m. Eastern Standard Time, Monday through Friday. If you are requesting a fast decision outside of normal business hours, be sure to call (not fax) us at:1-800-753-2851, or TTY/TDD should call toll-free 1-800-716-3231, and listen to the recording for further direction. Be sure to state that you are requesting a “fast,” "expedited," or “24-hour” review.