Pharmacy Exception Requests

Exception Requests

Providers and members can submit an exception request for drug coverage determination. These exceptions include:

  • Non-Formulary Drug Exception: A request to cover a non-formulary drug
  • Tier Exception: A request for a member to pay a lower tier cost-share for a non-preferred drug
  • 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

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 the provider and member. If an exception request is denied, a notice is sent to the provider and member explaining the reason why the request was denied and information on how to submit an appeal.

Non-Formulary Drug Exception

Certain drugs may not be covered on your patient’s formulary. There are several formulary options, so it depends on your patient’s plan which drugs are covered. If a drug is excluded, there is always an alternative drug option in the same drug class on the formulary. However, if there is medical necessity that requires the patient to be on the excluded drug, you can request an exception for coverage.

To see whether a drug is excluded, select the appropriate formulary.

To request a non-formulary drug exception:

Tier Exception

You may submit a request for your patient to receive a non-preferred drug at a lower cost-sharing tier if the non-preferred drug is medically necessary. There should be documentation to show that the lower-cost sharing alternative drug(s) were not effective.

To request a tier exception:

  • Fax a Tier Exception Form to CVS Caremark at 1-888-487-9257
  • Call CVS Caremark at 1-800-294-5979

Brand Exception

Depending on your patient’s benefits, if a non-preferred brand drug is filled when a generic alternative is available, your patient will pay the non-preferred brand copay or coinsurance plus the cost differential between the generic and non-preferred brand drug. You may submit a request for your patient to receive the brand-name drug when a generic alternative is available and only pay the applicable brand cost-share.

To request a brand exception:

Maintenance Medication Exception

Maintenance medications are used to treat chronic, long-term conditions, such as high blood pressure or diabetes, and are taken on a regular, recurring basis. Maintenance medications can be filled for up to a three-month supply.

If a drug is not on the Maintenance Drug List, you may submit a request for a drug to be considered maintenance. If the request is approved, the drug can be filled for up to a three-month supply. A maintenance medication exception is valid for one year. If the request is denied, the drug is still covered for the days’ supply allowed by the patient’s plan.

To request a maintenance medication exception: