Can I Appeal if My Medication is Not Approved?
Yes. Your doctor’s office can appeal the decision.
What Do I Need to Do?
An appeal must be in writing and include the following information:
- Member’s full name, date of birth, ID number
- Medication, strength and quantity being requested
- Complete diagnosis of member
- Listing of previous medications utilized for member, including medication strength, start date, end date and reason for stopping/changing each medication.
- Rationale for selection of medication for member based on diagnosis, including documentation of resources to support use of medication, if outside of FDA approved dose guidelines.
- Physician’s signature and date
All comments, documents, records and other information submitted by the member’s physician will be taken into account, without regard to whether such comment, document, record or other information was submitted or considered in the initial benefit determination.
The appeal should be mailed or faxed, on the physician’s letterhead, to:
FlexScripts Administrators: Appeals Department
10400 W. Innovation Drive, Suite 300
Milwaukee, WI 53226
There is no time limit for the submission of an appeal. When the appeal is received, it will be reviewed by the Director of Pharmacy and a decision will be communicated in writing to the member‘s physician.
In the case of a determination not involving urgent care, the decision will be communicated to the physician within 10 days from its receipt.