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It is usually helpful to include a letter of support from your prescribing physician. This letter should explain why similar drugs on the plans formulary at lower tiers are ineffective or harmful for you. Your plan must give you a decision within 72 hours of receiving the request.
Your doctor is your ally on this. Most plans require that your doctor submit a formulary exception on your behalf. The doctor will need to send paperwork to your health plan indicating the reason that you cant take the preferred medications and must have one that is not currently on the formulary.
A member can submit a formulary exception request by contacting us in writing or calling the member service number on the back of your ID card. Alternatively, a prescribing provider can submit a formulary request through the provider portal. If the drug is denied, you have the right to an external review.
Take it to your physician, go through your history and you may find you meet the terms for coverage. If you have a closed formulary and the drug(s) not on the formulary then you will need to reach out to patient assistance programs to determine if you qualify for financial assistance.
An exception procedure can be used by prescribers and patients to request coverage for drugs that are not included on a plans drug formulary. Through this administrative process, a plan can agree to cover medically necessary nonformulary drugs on a case-by-case basis.
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A coverage determination (exception) is a decision about whether a drug prescribed for you will be covered by us and the amount youll need to pay, if any.