It is our goal to provide a formulary and drug coverage that works well for all members. However, there are cases when exceptions can be considered by the plan. These are examples –

  • The drug you take is not covered by the plan (Non-Formulary).
  • The drug you want to take is covered, but there are extra rules or restrictions on the drug. For example, you need to try Drug A to see if it will work before Drug B can be covered (Step Therapy) or there are limits on the number of pills covered during a set time period (Quantity Limit).
  • The drug you take is covered, but it is in a non-preferred cost-sharing tier that makes your cost more expensive than you would like.

You and your doctor (or other prescriber) can ask the plan to make an exception to cover a drug differently. If your doctor believes you have medical reasons that justify an exception, he or she can help you request an exception.

You may complete an exception request by using this online form – Medicare Prescription Drug Coverage Determination Form.

If you are a current member and a drug you are taking will be removed from the Formulary or restricted in some way for next year, we will allow you to request an exception in advance for the next year. We will give you an answer to your request for an exception before the change takes effect. 

If your drug is not on the formulary, you can –

  • Change to another drug. Start by talking with your doctor. There may be a different drug on the formulary that might work just as well for you. You can ask your doctor to review the formulary for alternatives that might work for you.
  • File a Formulary Exception request. Your doctor can ask the plan to make an exception to the formulary so that you can obtain a nonformulary drug. If your doctor or other provider says that you have medical reasons that justify asking us for an exception (i.e. all of the alternative drugs on the formulary would be ineffective or would cause side effects for you), they can help you request a Formulary Exception. If approved, it would be covered at the cost-sharing amount that applies to Tier 4 (Non-Preferred Drugs).

If your drug is in a non-preferred cost-sharing tier, you can –

  • Change to another drug. Start by talking with your doctor. There may be a different drug in a lower cost-sharing tier that might work just as well for you. You can ask your doctor to review the formulary for alternatives that might work for you.
  • File a Tier Exception request. Your doctor can ask the plan to make an exception to the cost-sharing tier for the drug so that you pay less for it. If your doctor or other provider says that you have medical reasons that justify asking us for an exception (i.e. all of the alternative drugs in a lower tier would be ineffective or would cause side effects for you), they can help you request a Tier Exception.
    • If your drug is in Tier 4 (Non-Preferred Drugs), and is considered a brand name drug, your doctor can ask us to cover it at the cost-sharing amount that applies to drugs in Tier 3 (Preferred Brand).
    • If your drug is in Tier 4 (Non-Preferred Drugs), and is considered a generic drug, your doctor can ask us to cover it at the cost-sharing amount that applies to the lower-tiered alternative formulary drugs. 
    • If your drug is in Tier 2 (Generic), your doctor can ask us to cover it at the cost-sharing amount that applies to the lower-tiered alternative formulary drugs (if applicable).
    • Non-allowed tier exceptions: Brand Drugs cannot be reduced to Generic tiers and Specialty Medications are not eligible for tier exception.
This web page was updated on January 2, 2019.
facebook-sp  twitter-sp