Pharmaceutical Exception Request Form - 508 Pharmaceutical Exception Request Form - 508 2025

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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.
Exempt drug means a drug on the MTUS Drug List which is designated as being a drug that does not require authorization through prospective review prior to dispensing the drug, provided that the drug is prescribed in ance with the MTUS Treatment Guidelines.
Non-Formulary Drug Exception: A request to cover a non-formulary drug. Tier Exception: A request to cover a non-preferred drug at a lower tier cost share. Brand Exception: A request to cover a non-preferred brand drug at the applicable cost-share when a generic alternative is available.
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.
Exceptions requests are granted when a plan sponsor determines that a requested drug is medically necessary for an enrollee. Therefore, an enrollees prescriber must submit a supporting statement to the plan sponsor supporting the request.
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The exception process can be used to override benefit limits that are based on U.S. Food and Drug Administration (FDA)-approved durations of treatment or maximum dosing limits. A plan may limit drug benefit coverage to FDA-approved durations or dosing.
MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION You may also ask us for a coverage determination by phone at 1-866-235-5660, (TTY: 711), 24 hours a day, 7 days a week, or through our website at .silverscript.com. Who May Make a Request: Your prescriber may ask us for a coverage determination on your behalf.

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