3. How do I request a drug exception?

You or your physician could request an exception to have the plan cover your medication. If your physician says there are medical reasons to justify an exception, he/she can help you request an exception to the rule.

You can request different kinds of exceptions:

• If your prescription has a quantity limit, you may ask us to disregard this limit and extend our coverage.
• You may ask us to increase the level of coverage for your medication. This would reduce your copay.
• If your medication requires you to first use another medication, you may ask us to disregard the step-therapy requirement.

As a rule, we will only approve exception requests if a lower dosage or the prescription alternatives included in the plan’s Drug List would not be as effective to treat your condition and/or could result in adverse medical effects.

If we do approve your exception request, this approval will be valid for the remaining policy year, as long as your physician continues prescribing the medication and it continues being secure and effective to treat your condition. If we deny your request, you may appeal our determination. Please refer to your Evidence of Coverage for more information about filing appeals.

You can read more about it here (link to external page).