Exceptions

The first step in requesting an exception is to contact the plan. Your plan will explain how to submit the information they need to make a decision. The plan may request the information in writing. They also can choose to accept the information over the phone. Your physician must submit a statement confirming your request. The doctor's statement must establish that the requested drug is "medically necessary" for treating your condition. Once this information is submitted, your plan must notify you of its decision within 24 to 72 hours.

An exception is a type of coverage determination. You can ask us to make an exception to our coverage rules in a number of situations:

• You may request for us to cover your drug even if it is not on our formulary. Excluded drugs cannot be covered by a Part D plan unless coverage is through an enhanced plan.
  
  
• You may request to have us waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
  
  
• You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our non preferred/highest tier subject to the tier exception process, you may request us to cover it at the cost sharing amount that applies to drugs in the preferred/lowest tier subject to the tier exception process tier instead. This will lower the coinsurance/copay amount you must pay for your prescription. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. You may neither ask us to provide a higher level of coverage for drugs that are in the tier designated as the high cost/unique drug tier.

Generally, we will only approve your request for an exception if the alternative drugs included in the plan formulary or the drug in the non preferred/highest tier subject to the tier exception process would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

Your physician must submit a statement supporting your exception request. In order to help us make a decision more quickly, you should include supporting medical information from your doctor when you submit your exception request.

If we approve your exception request, our approval is valid for the rest of the plan year, as long as your doctor continues to prescribe the drug for you and it continues to be safe and effective for treating your condition. If we deny your exception request, you can appeal our decision.

Note: If we approve your exception request for a non formulary drug, you cannot request an exception to the copay or coinsurance amount we require you to pay for the drug.

See Section 9 of your Evidence of Coverage to learn more about how to request an exception.