Appeals
Pre-Service Denials — Non-Urgent
If a pharmacist will not fill your prescription and your situation is not urgent, it is recommended that you first try to resolve the situation informally as previously described. However, if you are not satisfied with the initial resolution or you believe that you have received some type of adverse benefit determination that is preventing you from filling a prescription, you or your authorized representative (such as your physician) can appeal the benefit denial/determination in writing within 180 days of receipt of the denial or adverse determination. Your appeal must be in writing and must include the following information: your name, member ID, phone number, the prescription drug for which benefit coverage has been denied, and any additional information that may be relevant to your appeal. The appeal should be sent to:
Express Scripts, Inc.
Attention: Appeals
P.O. Box 631850
Irving, Texas 75063-0030
A decision notice will be mailed to you within 15 days of receipt of your appeal. The notice will include the specific reason(s) for the decision and the Plan provision(s) on which the decision was based. You have the right to receive, upon request only and at no charge, the information used to review your appeal.
If you are not satisfied with Express Scripts' decision, you have 90 days from the date of your receipt of the decision notice to request a second-level of appeal. To initiate a second-level of appeal, you must submit the appeal in writing to Express Scripts' address. A decision will be made regarding your request and will be sent to you within 15 days of Express Scripts' receipt of the request. A qualified individual who was not involved in the review of your original appeal will review your appeal. If, at this point, your appeal is denied, you can initiate PG&E's Voluntary Review Process or you can bring a civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974 ("ERISA").
Pre-Service Appeal — Urgent
If a pharmacist will not fill your prescription as desired and your situation is urgent, you may request an expedited review by calling Express Scripts at 800-753-2851. In cases of an appeal for coverage involving urgent care, you will be notified of the benefit determination within 72 hours of Express Scripts' receipt of the appeal. An urgent appeal is any claim for treatment with respect to which the application of the time periods for a non-urgent care determination could seriously jeopardize the life or health of the claimant or the claimant's ability to regain maximum function or, in the opinion of a physician with knowledge of the claimant's medical condition, could subject the claimant to severe pain that cannot be adequately managed. You or your physician may submit an urgent appeal by phone or in writing. If the appeal does not contain sufficient information to determine whether benefits are covered, you will be notified of the missing information within 24 hours of Express Scripts' receipt of your appeal. You will then have 48 hours to provide the missing information to Express Scripts and will be notified by phone or in writing of Express Scripts' decision within 48 hours of receipt of the information. All written appeals must be sent to:
Express Scripts, Inc.
Attention: Appeals
P.O. Box 631850
Irving, Texas 75063-0030
If, at this point, your appeal is denied, you can initiate PG&E's Voluntary Review Process or you have the right to bring a civil action under Section 502(a) of ERISA.
Post-Service Appeals
If you paid for your prescription and believe that your level of coverage was incorrect, you can try to resolve this issue informally, as described previously under Claims and Inquiries. If this approach is unsatisfactory, you or an authorized representative, such as your physician, may appeal the decision in writing within 180 days of your receipt of the claim processing determination (e.g., pharmacy receipt). Your appeal must be in writing and must include the following information: your name, member ID, phone number, the prescription drug for which the level of coverage appears incorrect, and any additional information that may be relevant to your appeal. The appeal should be sent to:
Express Scripts, Inc.
Attention: Appeals
P.O. Box 631850
Irving, Texas 75063-0030
A decision notice will be mailed to you within 30 days of Express Scripts' receipt of your appeal. The notice will include the specific reason(s) for the decision and a reference to the Plan provision(s) on which the decision was based. You also have the right to receive, only upon request and at no charge, the information that Express Scripts used to review your appeal.
If you are not satisfied with the decision, you have 90 days from the date of your receipt of the notice to request a second-level of appeal. To initiate a second-level of appeal, you must submit the appeal in writing to Express Scripts' address. A qualified individual who was not involved in the review of your original appeal will review your second appeal. A decision will be made regarding your request and will be sent to you within 30 days of Express Scripts' receipt of your appeal. Express Scripts' decisions are based only on whether or not a benefit is covered by the Plan.
If at this point your appeal is denied, you can initiate PG&E's Voluntary Review Process or you can bring a civil action under Section 502(a) of ERISA.