Part D Coverage Determination and Exceptions
What If My Drug Is Not On The Formulary?
If your prescription is not listed on our formulary, ie. non-formulary, you should first contact Member Services to be sure it is not covered. If Member Services confirms that we do not cover your drug, you have three options:
- Talk to your doctor(s) to decide if you should switch to a similar drug on our formulary that is used to treat the same medical conditions.
- You can ask us to make an exception and cover your drug. See “How Can I Request An Exception to the Formulary”.
- You can pay out-of-pocket for the drug and request that the plan reimburse you. Unless it is an emergency, if you did not follow our exception process or the exception was not approved, your request for reimbursement may be denied. If we deny your request for reimbursement, you have the right to file an appeal.
If you recently joined our plan and learn that we do not cover a drug you were taking when you joined our plan, you may be able to receive a one-time fill of that prescription. You can receive a one-time fill of the non-formulary drug if one of the following applies:
- You didn’t know that your drug wasn’t covered.
- You knew it wasn’t covered, but you didn’t know that you could request an exception to the formulary.
After your one-time fill, we can help you identify similar drugs on our formulary that are used to treat the same medical condition. If we cannot find another drug for you, we will help you file a request for an exception to our formulary.
In some cases, we will contact you if you are taking a drug that is not on our formulary. We will let you know that your drug is not covered and help you identify similar drugs on our formulary that are used to treat the same medical condition.
How Can I Request An Exception to the Formulary?
You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
- You can ask us to cover your drug even if it is not on our formulary.
- You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
We will usually only approve your request for an exception if the alternative drugs included on the plan’s formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
In most cases, if we do approve your request for an exception, the exception is good for the rest of the year or the length of treatment approved.
Process for Filing an Exception (also known as a request for a “coverage determination”)
To request an exception, your prescribing provider may either call us or fax the request. If your health requires it, ask us to give you a "fast coverage decision". A "fast coverage decision" is called an "expedited coverage determination". When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "fast" deadlines. A standard coverage decision means we will give you an answer within 72 hours after we receive your doctor's statement. A fast coverage decision means we will answer within 24 hours.
If your prescribing provider requires an immediate response, the pharmacist will contact the on-call pharmacist who will respond to the prescriber as quickly as possible.
To request an exception, your prescribing provider needs to provide the following information:
Your full name (First name and Last name)
Your Member ID number
Requested drug
Reason for the exception
Once an exception request is approved, it is valid for the remainder of the plan year or the length of therapy authorized so long as your prescribing provider continues to prescribe the drug for you and it continues to be safe and effective for treating your condition.
To request an exception (Coverage Determination) you and your prescribing provider can do the following:
- Call Toll Free: 1-844-786-6762 (TTY: 711), 24 hours a day, 7 days a week.
- Fax the Request: 1-855-633-7673
- Write to:
CareFirst BlueCross BlueShield Medicare Advantage
c/o CVS Caremark
P.O. Box 52000, MC109
Phoenix, AZ 85072-2000