A member or provider may request an exception for non-covered formulary medication
in lieu of a covered medication by submitting a letter of medical necessity from
the prescribing provider. Information must be submitted by the provider on letterhead
via a letter of medical necessity including the following: member name, failed therapies,
diagnosis, and member identification number. The letter should be faxed to the attention
of the Pharmacy department at 501-378-6980. Medical records may be requested to
demonstrate the medical need for the excluded drug. Once all necessary information
is received, a determination will be made within 72 hours and the member and provider
will be notified. Expedited review requests due to exigent circumstances must be
noted as such on the letter and must contain all required information, in order
to be reviewed within 24 hours of this request.
If the member's request is denied, the member has the right to request an appeal.
Appeal information must be submitted in writing and must include the reason the
member and/or the provider disagrees with the determination and any supporting information.
Mail appeals to:
Arkansas Blue Cross Blue Shield
Attn: Appeals Coordinator
PO Box 2181
Little Rock, AR 72203-2181
Urgent appeals may be faxed to 501-378-3366. The member and/or physician may request
a clinically appropriate specialist or an external review organization to review
the request. This request must be submitted in writing and may be faxed.
Arkansas Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association and is licensed to offer health plans in all 75 counties of Arkansas.
Copyright © 2001-2017 Arkansas Blue Cross and Blue Shield