An exception is a type of coverage determination.

You can ask for an exception if a drug is not covered or if you need a change to how it is covered.

• Your doctor must explain why the exception is medically necessary
• We will review the request and make a decision

If we deny your request, you have the right to file an appeal.

A request may be made by:

• You (the member)
• Your authorized representative
• Your prescriber (doctor or other licensed provider)

You can request a coverage determination for:

• A drug that is not on your plan’s List of Covered Drugs (Formulary)
• A drug you believe you need that is not listed on the formulary
• A prescription your pharmacy cannot fill as written
• Removing a coverage restriction (such as prior authorization)
• Changing a drug to a lower cost-sharing tier
• Paying less for a higher-tier drug when lower-cost options are not appropriate
• Requesting payment for a prescription drug

• Your doctor will help request the exception and provide medical reasons
• We can approve or deny your request
• If approved, the exception usually lasts through the plan year, as long as the drug remains safe and effective for you
• If denied, you can file an appeal
• If your health requires a fast decision, you can request an expedited review