Commonwealth Care Alliance

Senior Care Options Program (HMO SNP)

Pharmacy » Prescription Coverage » Request Exception to Formulary

Request Exception to Formulary

You can ask Commonwealth Care Alliance to make an exception to coverage rules. There are different types of exceptions you can ask us to make, such as:

  • 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, Commonwealth Care Alliance 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.

Generally, Commonwealth Care Alliance will only approve your request for an exception if the alternative drugs included on the plan’s formulary, or additional utilization restrictions, would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

How do I request an exception to Commonwealth Care Alliance’s formulary?

You, your physician, or your appointed representative may file the exception.

  • Call us: 1-866-270-3877 – You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception.
  • Submit the Coverage Determination Request Form and a physician’s supporting request.
    When you are requesting a formulary or utilization restriction exception, you should fax or mail the form below and a statement from your physician supporting your request.

    • Download  the Model Drug Coverage Determination Request Form (pdf)

Fax: 1-855-668-8552

Mail: Navitus Health Solutions
P.O. Box 1039
Appleton, WI 54912-1039

Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s supporting statement.

 

To view the PDF files above, you may need to download a free copy of Adobe® Acrobat Reader software on your computer. (This link takes you away from the Commonwealth Care Alliance website pages.) Click here for more information about Adobe Acrobat.

 

H2225_SCOweb-RequestExpt Approved

Last Updated 12/30/2015