What does the appeal process look like for patients that get a denial, does the office need to request appeal or is automatically processed?

As soon as PhilRx receives the PA denial, PhilRx will automatically initiate the appeal and notify the office that an appeal is required. PhilRx will follow up with the office to remind them to submit the appeal on business day 2 and 4 of the 7 day appeal timer. The first follow up will be a fax, the second follow up will be a call to the office. 

Per the business rules, the Appeal fax sent to the office will include the patient, plan, and medication information along with a sample letter of medical necessity. These forms have been reviewed and approved by the manufacturer's Compliance team.

To keep the patient updated with the progress of their order, the Phil system will send the following approved message to the patient when an appeal is initiated: 

• SMS TEXT:- Update from PhilRx: Your insurance didn't approve coverage for your [Drug name], so we have notified your doctor that an appeal is available. This can take up to 30 days, and we'll update you on the progress. No action is needed from you at this time.