Coverage Determinations and Exceptions

The coverage determination may be requested by your doctor, by you as the member, or by a representative you have authorized who has completed the Appointment of Representative documentation required by the plan. The request may be made verbally or in writing. In order to protect your privacy and confirm your identity, a representative of our plan may contact you, your doctor, or your authorized representative to request more information or additional documentation.

Generally, we will only approve your exception request if the alternative drugs included on the plan’s Formulary or the non-preferred/higher-tier drugs subject to the exception process are not effective in treating your condition and/or may cause you an adverse medical reaction.

Your doctor must submit a justification supporting the exception request. To help us make a faster decision, you should include your doctor’s supporting medical information when you submit your exception request. The plan will issue a decision on the case within 72 hours (standard request) after receiving your doctor’s written statement. If you believe the 72-hour review period could adversely affect your health, you may request an expedited decision. Simply indicate on the request that an expedited review is needed, and a decision will be issued within 24 hours or less from receipt of the doctor’s statement.

If we approve your exception request, our approval will be valid for the rest of the contract year, as long as your doctor continues to prescribe the drug and it continues to be safe and effective in treating your condition. If we deny your exception request, you may appeal our decision.