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you have pretty good odds of getting the formulary exception approved when it is a continuation of therapy (in your case) vs a new therapy. they will just have to document what youve tried and failed, and how what youre on now is working well for you and usually it is approved when you are already on the medication.
A formulary exception is a request to your insurance company to cover a non-formulary drug. This request is typically initiated by your provider, who will provide supporting documentation, accompanied by a letter of medical necessity (LMN), to explain why the requested medication is necessary for your treatment.
Non-formulary medicines should be prescribed only when formulary choices are not suitable or have been exhausted. Non-formulary prescribing should not be used to bypass usual NHS commissioned pathways.
A doctor may prescribe a non-formulary drug when covered therapies havent been effective for you. If you and your doctor have decided that a non-formulary drug is right for you, your doctor can request approval. Getting approval helps you lower your out-of-pocket costs.
You can get an exemption so that you wont have to pay a penalty for not having qualifying health insurance. Some exemptions require an exemption application through Covered California. Other exemptions do not require an application: Instead, you can claim them when you file your state tax return.
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