Regence Pharmacy Peer-to-Peer (P2P) Review Request Form for Medications
(provider-administered)


If you would like to speak with a clinical reviewer about the denial of a provider-administered medication pre-authorization (PA) request, please complete this form to arrange for a peer-to-peer (P2P) discussion.

Please call Pharmacy Customer Service for all inquiries related to retail medications.


Pharmacy Customer Service: 1 (844) 765-6827
Provider Customer Service: 1 (800) 253-0838
Medicare Customer Service: 1 (866) 749-0355


  • What is a P2P? A P2P is a telephone conversation between a provider and a clinical pharmacist.
  • Who does the P2P? Pharmacists conduct all P2P calls for medications. Medical directors are available to answer any additional (unanswered) clinical questions.
  • When can the P2P be done? The P2P must be requested:
    • within 15 calendar days of the date on the preauthorization denial letter;
    • BEFORE an appeal has been initiated. We are unable to conduct P2P calls once an appeal has been initiated (for non-Medicare members).
  • When is a good time to talk?
    • Please provide two preferred call windows (time frames) for the P2P call and a direct line, so our staff can reach you.
    • Please ensure the provider receiving the call has agreed to the call windows.
    • We are happy to call anytime between 9:00 am and 4:00 pm PST but prefer two hours to gather information for the call. We are committed to returning the call same day, if requested.

This process is intended to:

  • Be a dialogue about a decision (denial) only BEFORE services are performed.
  • Discuss policy coverage criteria and the evidence used for a determination.
  • The call may also allow for a discussion to clarify the clinical situation and/or discuss potentially coverable treatment alternatives, if needed.

This process is NOT for:

  • Opening expedited appeals. Opening an appeal is the best course of action for reconsideration of a decision. An appeal can be opened via phone or fax.
  • Contract exclusions or reimbursement issues (including copays). Please contact our Provider Customer Service Team by phone at 1 (800) 253-0838 if you have any questions.
  • Post-service review. If services were rendered (meaning the medication was already administered) and you disagree with the decision, you will need to submit an appeal to Provider Services rather than a peer-to-peer discussion. Opening a post-service appeal.
  • General policy feedback. If you have a general, non-patient-specific question for a pharmacist and/or feedback on a specific medication policy, please click here to email.

If the answers to all the questions below are yes, a P2P for this provider-administered medication-related call may be conducted.

If the request does NOT meet these criteria and you wish to submit an appeal, please refer to the denial letter.


Question

Yes

No

1. Is this request for a MEDICATION-related question?

Please click here to submit a P2P request for a non-MEDICATION question.

Yes No
2. Is this request for a Regence group member and not for a member of the Federal Employees Program (FEP) or HMSA plan(s)?

Please click here for a FEP or HMSA member.

Yes No
3. Is this request for a medication denial related to a pre-authorization request?
  • PA; PRE-service, meaning the PA was requested before a medication is administered.
  • We do not offer P2P for denials of other services that have already been provided - those are handled through the appeal process. We send notification letters regarding post-service, member liability denials that are eligible for P2Ps.
  • If you wish to submit a post-service appeal, please refer to the denial letter.
Yes No
4. Is this the first P2P you have requested for this patient and service?

Note: Additional P2Ps are ONLY allowed for new/different denial (i.e., a request for a different medication regimen or a different diagnosis). We are unable to return call requests for denials on the same medication request, such as for each level of appeal.

Yes No
5. Do you understand a medication-related P2P conversation is not specialty-matched?
  • All medication P2P requests are returned by a clinical pharmacist.
  • The Regence Clinical Pharmacy Services staff maintain all the health plan medication policies and are well versed in the evidence used for policy development.
  • If a pharmacist is unable to answer your clinical questions, a call may be subsequently scheduled with a Medical Director.
  • Medical Directors schedule calls within 2-3 business days. Pharmacists return calls as quickly as within two hours (but always the same day, if requested between 9:00 am and 4:00 pm PST).
Yes No
6. Do you understand that a P2P is NOT an appeal?
  • Instead, it is a clinical discussion about a case to further understand the reason(s) for the denial, based on our policies, and to gather any additional relevant clinical information. A P2P is NOT intended to overturn a denial.
  • If you would like to open an appeal, please refer to the denial letter.
  • NOTE: New information about the service must be submitted as an appeal.
Yes No
7. Is the provider aware the P2P is being requested? Yes No
8. Does the provider understand the specific reason for the denial and has the provider read the denial letter?

For hyaluronic acids (Euflexxa, Gel-One, Orthovisc, Supartz, Synvisc/One, etc.):

  • Please carefully review the denial letters for the policy position on hyaluronic acid.
  • Hyaluronic acids are NOT coverable for commercial (non-Medicare) members.
  • Some self-insured groups have a specific policy for these medications (also NOT covered).
Yes No
9. Do you understand that a P2P request will not be available if an appeal has already been submitted and is currently in process?
  • Appeals are sent externally for specialty-matched review. Therefore, we are unable to discuss appeals when the decision is being considered outside of the Regence Clinical Pharmacy Services department.
  • Please note: P2P requests for Medicare members will be considered regardless of whether an appeal has been submitted or not.
Yes No
10. Are you able to meet the schedule availability requirements as outlined?
  • Provide at least two different one-hour time periods, between the hours of 9:00 a.m. and 4:30 p.m., Monday through Friday (Pacific Standard Time).
  • Please allow at least two hours from the time of submission to the first call window. This allows us to identify and compile all related information prior to the P2P call.
  • Please ensure:
    • The provider will be available;
    • A direct line is provided for the call, to avoid a delay in contacting the provider.
    • If either of the requested time periods is during a lunch hour (when phones may be turned off), the provider or an office staff person (not an answering service) must answer the phone.
  • If we have any questions or a need to reschedule the time periods you indicated, we will contact you using the office phone number provided.
Yes No
11. Is the listed phone number a direct line?

Note: telephone numbers will NOT be shared, including cell phones. Direct phone lines expedite our timely return of calls.

Yes No
12. Please read the following and indicate you acknowledge:
  • If the provider is not available, the pharmacist will leave a voice mail (no PHI, unless the recording states it is secure) and the call will be attempted during the second call window.
  • If the provider is not reached during the second attempt, a second voice mail will be left and no additional calls will be made out. A new P2P request (including new call times) will need to be requested.
Yes No

Medication Requested and Member Information

Medication name for P2P discussion:
Clinical question:

Please provide a brief description of the specific clinical question.

Member first name:
Member last name:
Member ID number with alpha prefix:
Medicare member? Yes No
Date of birth:
State:

Provider Information

Your name and position (as the individual submitting this form):
Your telephone number (office or direct phone number) for coordination:
Your email address (to receive a confirmation email):
Provider first name:
Provider last name:
Provider credential (MD, DO, NP, PA, ND, RPh, etc.):
Provider phone number for P2P (please note if this is a pager number):

Requested Call Windows

Date Start Time
End Time
(between 9:00 am and 4:30 pm PST)
Time Zone Additional Instructions

(e.g. ok to leave message, ask for specific person)

Start time:
End time:
Start time:
End time:
Start time:
End time: