Pharmacy External Peer Review

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MRIoA currently provides physician and pharmacist peer review for many of the largest PBM's in the country

Over the last decade MRIoA has seen a steady increase in the amount of pharmacy business we process. The reason for this surge is due mostly to satisfied clients referring their peers. As a result, MRIoA processes a high volume of pharmacy cases for some of the nation's largest pharmacy benefits managers. MRIoA has the knowledge and experience needed to review many different types of pharmacy cases. Case types include: drug prior authorizations, medical necessity of drug therapy, coverage determinations, tiered drug therapies, step therapy drugs, drug dosage and quantity limits, Medicare Part D coverage determinations, re-determinations and exception requests.

In 2011, MRIoA created a team fully dedicated to pharmacy review and our pharmacy clients. Our pharmacy department consists of highly trained pharmacists, pharmacy technicians and analysts who are committed to providing the highest level of service and quality to each of our clients and to their individual needs. The team is also very knowledgeable when it comes to implementing new clients, evaluating processes and creating a seamless submittal and review process.

Realizing that most of our pharmacy clients are working under tight timeframes, MRIoA offers same day, 24 and 48 hour turnaround times. In addition, we also provide weekend & holiday review service, when needed, to ensure that any time frame will be met. Whether a case is being reviewed by a physician or a pharmacist, MRIoA's pharmacy clients can expect a quick turnaround time on their cases. However, that doesn't mean quality suffers. Our quality audit process ensures that every case, no matter how fast the TAT, will be of the highest quality and value.

Prior Authorization (P/A) / Initial criteria reviews

  • Case review based on P/A or other criteria
  • Same day response
  • Reviews available by a Pharmacist or MRIoA Medical Director (Medical Directors board certified in Neurology, Family Practice, Internal Medicine & Emergency Medicine)
  • Medical Directors licensed in most states with same state licensure requirements
  • P/A reviews can also be performed at the specialist level if required
  • A phone consult with the Provider is available upon client request

First-Level Review

  • Cases reviewed based on criteria, medical necessity or other guidelines
  • Cases can be reviewed at the Pharmacist, Medical Director or specialist level (depending on client needs)
  • Initial, Appeal, Grievance or Panel review available
  • Response times average 1.5 business days or less
  • Same day, 24 hour & 48 hour service available
  • A phone consult with the Provider is available upon client request

Second-Level Review

  • Offers the same options as First-Level Review, but can be modified to meet your internal appeal needs
  • Same day response available

For questions regarding pharmacy review please contact the MRIoA marketing department at 800-654-2422 ext. 6453

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"We don't have a lot of claims to be reviewed, but it is reassuring that MRIoA is there when we do need someone."