Prescription Drug  Exception Process

A Member, a Member’s Authorized Representative or a Member’s prescribing Physician may request an exception to our Prescription Drug requirements, including but not limited to: 

1. A substitution of a Preferred Drug, therapy or medication including specialty and no Specialty Drugs except vaccines; 
2. Drug benefit limitations and procedures under our drug utilization management program such as step therapy; dosage limitations or therapeutic substitutions; 
3. Access to drugs, therapies or medication that are on and off of our Prescription Drug Formulary; 
4. Continuation the use of a drug if the tiering structure changes during the year, and the Member is using the drug at the time of the change.

To request an exception, complete the Prior Authorization Request Form for Prescription Drugs (PDF).

To request a step therapy exception, complete the Step Therapy Exception Request Form (PDF).

To check whether medication has any coverage restriction, refer to the Clinical Policies.

Requests for non-formulary drugs, under the pharmacy benefit, will be reviewed against medication-specific prior authorization criteria when available.  If there are no medication-specific criteria, request will be subject to the policy HIM.PA.103 – Brand Name Override and Non-Formulary Medications (PDF).

Non urgent exception request

A member, a member’s designee or a member’s prescribing Physician may request a standard Prescription Drug exception review. The request can be made in writing or via telephone. If we do not receive enough information to make a decision, we will notify the prescribing Physician and indicate the specific information we need.

Urgent (Expedited) exception request

A member, a member’s designee or a member’s prescribing Physician may request an expedited review based on exigent circumstances. Exigent circumstances exist when a member is suffering from a health condition that may seriously jeopardize the member’s life, health, or ability to regain maximum function or when a member is undergoing a current course of treatment using a nonformulary drug. If we do not receive enough information to make a decision, we will notify the prescribing Physician and indicate the specific information we need to make a decision. 

The request can be made in writing or via telephone.