the member cost-share (coinsurance, if applicable). If WSRxS decides not to cover the prescription drug (denies the appeal), you are responsible for the full cost of the drug. If you disagree with the expedited appeal decision, you or your provider may request an expedited external review (see the “External review (independent review)” section below). Time limits for the plan to decide appeals ALERT! The plan will comply with shorter time limits than those below when required by federal or Washington State law. The time limits for both first- and second-level appeals are calculated from when the plan receives the appeal. The plan will decide your appeal within 14 days of receiving it but may take up to 30 days unless a different time limit applies as explained below. The plan will request written permission from you or your authorized representative if an extension to the 30-day time limit is needed to get medical records or a second opinion. For expedited appeals, the plan will decide as soon as possible but always within 72 hours. The plan will notify you (or your authorized representative) of the decision verbally within 72 hours and will mail a written notice within 72 hours of the decision. External review (independent review) You or your authorized representative may submit a request for an external review by an independent review organization (IRO) if you have gone through both a first- and second-level appeal (or expedited appeal) and your appeal was based on the plan’s decision to deny, modify, reduce, or terminate coverage of or payment for a health care service. You may also submit a request for an external review: • If the plan has exceeded the timelines for response to your appeal without good cause and without reaching a decision; or • If the plan has failed to adhere to the requirements of the appeals process. You may submit a request for an expedited external review if you meet the requirements for the expedited process as described above. You may also request an expedited external review at the same time that you request an expedited appeal, called concurrent expedited review. When you request concurrent expedited review, you are not required to go through both a first- and second-level appeal. An IRO will conduct the external review. An IRO is a group of medical and benefit experts certified by the Washington State Office of the Insurance Commissioner and not related to the plan, Regence BlueShield, WSRxS, or HCA. An external review provides unbiased, independent clinical and benefit expertise to determine whether the plan’s decision is consistent with state law and the 2024 UMP Plus––PSHVN (PEBB) Certificate of Coverage. Requesting an external review To request an external review, see the contact information listed in the “Where to send complaints or appeals” section below. You or your authorized representative must submit a request for an external review no more than 180 days after you receive the letter responding to your second-level appeal (or expedited appeal). Only the member or an authorized representative may submit a request for an external review. You may authorize 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage 129