University Of Michigan Benefits Office

PA Appeals Process

In the event that your physician prescribes a drug that was not dispensed or was not Prior Authorized (PA), you may contact SXC about an appeal. The appeals process is described in detail below.

The University has provided criteria to SXC to follow when considering and reviewing appeals. The University reviews the appeal topics on an ongoing basis. Patient specific information regarding an appeal is not shared with the University by SXC.

Claims appeal forms are available from the Benefits Office Forms page.

Note: The plan will not consider appeals for lower co-pay levels on covered drugs. The plan will not consider appeals for increased levels of coverage for plan exclusions and limitations.

A list of drugs that require prior authorization as well as standard excluded drugs is located on this Web site. Your physician can call SXC prior to your filling Prior Authorized prescriptions at the pharmacy in order to expedite the process.

Understanding the SXC Prior Authorization and Appeal Process

Prior Authorization (PA)
A select number of drugs are placed on the University of Michigan Prior Authorization (PA) drug list because the drugs have patient safety concerns, quantity limits, or extremely high cost. Even if you have a written prescription from your physician this does not automatically mean the University drug plan will pay for the prescription when it requires a PA. The goal of the PA is to ensure medications are being appropriately prescribed and used. As part of the decision process to have the drug approved and dispensed, the University and SXC have developed specific criteria regarding the "standard indication" for use of the drug and quantity limits for each drug.

Before the prescription is written and you go to the pharmacy, your physician should call the SXC Physician PA desk (1-866-715-0874) to get approval. The PA is also needed for drugs dispensed at the mail order pharmacy. If the PA has not been arranged and you try to get the drug dispensed at the pharmacy, the pharmacist will get an electronic message saying the PA is "required." The pharmacist will either contact your physician about getting the required PA or notify you to contact your physician. In either case there may be a delay in getting the medication, so it is best to have your physician's office call before the prescription is written.
After your physician contacts SXC, the drug is either approved or denied. In the event the PA is denied, you and your physician will receive a letter. The letter will explain the reason for the denial.
Patient specific information regarding your prior authorization is not shared with the University of Michigan by SXC.
You have a right to the appeal process that, based upon new information provided by your physician, could result in the denial being overturned.
At any time you may purchase a drug without a PA approval. If the appeal is overturned, you may request reimbursement from SXC for the cost of the drugs. You will not be reimbursed for denied claims when the denial is upheld.

Appeal Process (1st Level)
The 1st level of the appeal process is a review to determine if the drug is covered based on the University of Michigan Prescription Drug Plan design and other criteria. The 1st appeal level will occur within 15 days and "urgent" appeals can be done within 72 hours. Patient specific information regarding your appeal is not shared with the University of Michigan by SXC. If you have an existing prescription for the medication (not a new medication), the University will provide you a 30-day override until your appeal is reviewed. To obtain an override during the appeal process, contact the Benefits Office.

The 1st level appeal determines if the requested use meets the criteria for the standard indications such as FDA and manufacturer recommendations. In addition, any new information provided by your physician is considered.

To Appeal a Prior Authorization denial:

Obtain the appeal form (contains all instructions) by calling SXC Member Services at 1-866-715-0874, or download the Prescription Claim Appeal form from the Benefits Office Forms page.
Complete the appeal form and attach any letters or other information that supports your appeal. Fax or mail the appeal form to SXC.
Your appeal with be reviewed by a pharmacist and you and your physician will receive a written response.
If your appeal is denied you have 180 days from the original PA denial to appeal the decision based on "medical necessity."
If the 1st level appeal is denied, you have the right to a second level appeal.

Appeal Process 2nd Level - Medical Necessity

At the 2nd level of appeal, an independent specialist physician outside of SXC will review your appeal. This includes a review of any records provided, a review of the medical literature, and discussion of the medical necessity request with your physician. The 2nd level appeal usually takes 5-7 days and no more than 15 days. Patient specific information regarding your appeal is not shared with the University of Michigan by SXC.
Medical necessity means that there is solid, credible evidence for the use of the drug for your condition.
You and your physician will receive a written rationale in support of the final decision.