Coverage Determinations: Clinical review of requests for medications to confirm eligibility and appropriateness.

Exceptions Management: Evaluate and approve requests for medications outside of formulary, prior authorization, or quantity limits when clinically appropriate.

Appeals Processing: Fair and timely review of member or provider appeals regarding coverage or prior authorization decisions.

Regulatory Compliance: Adheres to CMS, state, and commercial payer guidelines for response timelines and documentation.

Reporting & Analytics: Tracks trends, outcomes, and turnaround times for continuous improvement.