If you think that an error has been made in processing your prescription drug claim or in a prescription benefit determination or denial, first call Express Scripts or RDT (depending on the nature of your complaint) to ask for details. If you are not satisfied with the outcome of your telephone inquiry, the second step is to appeal to Express Scripts or RDT in writing. Please have your physician provide any additional relevant clinical information to support your request. Mail your request with the above information to:
Express Scripts or RDT will respond in writing to you and/or your physician with a letter explaining the outcome of the appeal. If this does not resolve the issue, the third step is to appeal in writing to the director of PEIA. Your physician must request a review in writing within sixty (60) days of receiving the decision from Express Scripts or RDT.
Director, Public Employees Insurance Agency, 601 57th St. SE, Charleston, WV 25304-2345.
Facts, issues, comments, letters, Explanations of Benefits (EOBs), and all pertinent information about the claim and review should be included. When your request for review arrives, PEIA will reconsider the entire case, considering any additional materials that have been provided. A decision, in writing, explaining the reason for modifying or upholding the original disposition of the claim will be sent to the covered person or his or her authorized representative. For more information about your drug coverage, please contact Express Scripts at 1-855-224-6247.
External Review: If we have denied your request for the provision of or payment for a health care service or course of treatment, our decision may be reviewed by independent health care professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care or effectiveness of the health care service or treatment you requested. An external review may be initiated by us or requested by you. You may submit a request for external review within 4 months after receipt of the notice of denial to the PEIA Clinical Unit, 601 57th Street, SE, Suite 2, Charleston, WV 25304-2345. For standard external review by your request, a decision will be made within 45 days of receiving your request. If you have a medical condition that would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function if treatment is delayed, you may request an expedited external review of our denial. If our denial to provide or pay for a health care service or course of treatment is based on a determination that the service or treatment is experimental or investigational, you also may request an external review of our denial. External review is the final level of appeal, regardless of whether the external review was initiated by us or requested by you. External review is not available for drugs, services or items which are simply not covered by the Plan. External review is also not available for out-of-state benefit level appeals or for a change in drug cost-sharing tier.