Pharmacy Exception Requests
You and your doctor can submit an exception request for drug coverage. These exceptions include:
- 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
- Maintenance Medication Exception: A request for a drug to be considered maintenance
- Step Therapy Exception: A request for a drug to bypass step therapy guidelines
Exception requests are reviewed based on medical necessity. Once an exception request is received with complete clinical information, the turnaround time for a determination is within 48 hours for non-urgent cases and within 24 hours for urgent cases.
If an exception request is approved, a notice is sent to you and your doctor. If an exception request is denied, a notice is sent to you and your doctor explaining the reason why the request was denied and information on how to submit an appeal.
For more information on exception requests and how your doctor can request an exception, visit our provider page.