What If My Drug Is Not On The Formulary?
If your prescription is not listed on our formulary, ie. non-formulary, you should first contact Member Services to be sure it is not covered. If Member Services confirms that we do not cover your drug, you have three options:
If you recently joined our plan and learn that we do not cover a drug you were taking when you joined our plan, you may be able to receive a one-time fill of that prescription. You can receive a one-time fill of the non-formulary drug if one of the following applies:
After your one-time fill, we can help you identify similar drugs on our formulary that are used to treat the same medical condition. If we cannot find another drug for you, we will help you file a request for an exception to our formulary.
In some cases, we will contact you if you are taking a drug that is not on our formulary. We will let you know that your drug is not covered and help you identify similar drugs on our formulary that are used to treat the same medical condition.
How Can I Request An Exception to the Formulary?
You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
We will usually only approve your request for an exception if the alternative drugs included on the plan’s formulary or the low-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
In most cases, if we do approve your request for an exception, the exception is good for the rest of the year or the length of treatment approved. Note: Drugs on Tier 5 are not eligible for a Tiering Exception.
Process for Filing an Exception (also known as a request for a “coverage determination”)
To request an exception, your prescribing provider may either call us or fax the request. If your health requires it, as us to give you a "fast coverage decision". A "fast coverage decision" is called an "expedited coverage determination". When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "fast" deadlines. A standard coverage decision means we will give you an answer within 72 hours after we receive your doctor's statement. A fast coverage decision means we will answer within 24 hours.
If your prescribing provider requires an immediate response, the pharmacist will contact the on-call pharmacist who will respond to the prescriber as quickly as possible.
To request an exception, your prescribing provider needs to provide the following information:
Your full name (First name and Last name)
Your Member ID number
Reason for the exception
Once an exception request is approved, it is valid for the remainder of the plan year or the length of therapy authorized so long as your prescribing provider continues to prescribe the drug for you and it continues to be safe and effective for treating your condition.
To request an exception (Coverage Determination) you and your prescribing provider can do the following:
Request for Medicare Prescription Drug Coverage form.