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 Non-Formulary and 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 againstmedication-specific prior authorization criteria when available.  If there are no medication-specificcriteria, 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.