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.
- 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 (Step Therapy) can be covered 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 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 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. You may view the formulary here. You can then ask us to make an exception and cover the drug in the way you would like it to be covered for the following year. We will give you an answer to your request for an exception before the change takes effect.
If your drug is in a cost-sharing tier you think is too high, 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 call Customer Service to ask for a list of covered drugs that treat the same medical condition. This list can help your doctor to find a covered drug that might work for you.
- File a Tier Exception request. You and your doctor can ask the plan to make an exception in the cost-sharing tier for the drug so that you pay less for the drug. If your doctor or other provider says that you have medical reasons that justify asking us for an exception, your doctor can help you request an exception to the rule.
- If your drug is in Tier 4: Non-Preferred Drugs, and is considered a brand name drug, you can ask us to cover it at the cost-sharing amount that applies to drugs in Tier 3: Preferred Brands. This would lower your share of the cost for the drug.
- If your drug is in Tier 4: Non-Preferred Drugs, and is considered a generic drug, you can ask us to cover it at the cost-sharing amount that applies to drugs in Tier 1: Preferred Generics. This would lower your share of the cost for the drug.
- If your drug is in Tier 2: Generics you can ask us to cover it at the cost-sharing amount that applies to drugs in Tier 1: Preferred Generics. This would lower your share of the cost for the drug.
- Non-allowed tier exceptions: Brand Drugs cannot be reduced to Generic tiers and Specialty Medications are not eligible for tier exception.
This webpage was updated on October 26, 2016.