Formulary Exceptions

If your plan does not cover a medication you need, is placed in a higher-cost tier, or is subject to a coverage rule that may not be appropriate for your situation, you may be able to request an exception.

An exception is a request asking the plan to make a special coverage decision based on your medical needs.

What Is a Formulary Exception?

A formulary exception is a request to cover a medication that is not included on your plan’s drug list (formulary).

You, your doctor, or your authorized representative may request a formulary exception if:

• Your medication is not on the formulary
• Covered alternatives have not worked for you
• Covered alternatives are not medically appropriate for your condition

If the exception is approved, the medication will be covered under your prescription drug benefit.

What Is a Tiering Exception?

A tiering exception is a request to cover a medication at a lower cost-sharing tier.

You, your doctor, or your authorized representative may request a tiering exception if:

• The plan covers your medication
• The medication is placed in a higher-cost tier
• Lower-tier alternatives are not medically appropriate for you

If approved, your out-of-pocket costs for the medication may be reduced.

Supporting Information From Your Doctor

Both formulary exceptions and tiering exceptions require a supporting statement from your prescriber.

Your doctor must explain why:

• Covered alternatives would not be as effective
• Covered alternatives may cause adverse effects
• The requested medication is medically necessary for your condition

Without supporting documentation from your prescriber, the request may be denied.

How to Request an Exception

You, your doctor, or your authorized representative may request an exception.

Requests may be submitted by:

• Phone
• Mail
• Fax
• Coverage Determination Request Form
• Physician Exception Request Form

Your doctor may also submit supporting clinical information directly to the plan.

Need a Faster Decision?

You or your doctor may request an expedited decision if waiting for a standard review could seriously harm your health.

Expedited requests are generally reviewed within 24 hours after all necessary information is received.

What If My Exception Request Is Denied?

If we deny your exception request, you have the right to appeal.

Learn more about drug coverage determinations, appeals, and your rights under your Medicare prescription drug benefit.

Need Help?

If you have questions about exceptions, prescription drug coverage, or the information your doctor needs, Member Services can help.