In some cases, it may be possible to receive an exception
for non-formulary or non-preferred formulary drugs.
If a drug your doctor prescribes is not on our formulary, or if the drug is subject to one of our Utilization Management requirements, such as step-therapy or quantity limits, you or your doctor can request a Formulary Exception. A non-formulary drug that we approve through the Formulary Exception Process will be considered a non-preferred generic (Tier 2) or non-preferred brand (Tier 4) drug.
Physician supporting statement for a formulary exception
In order for us to consider a request for a formulary exception, the prescribing physician must provide an oral or written supporting statement that the requested drug is medically necessary to treat your condition because:
- All of the covered drugs on any tier of the formulary available for treatment of your condition would either not be as effective for you as the nonformulary drug and/or would be harmful for you; or
- The prescription drug alternatives listed on the formulary or required to be used in accordance with step therapy requirements have been ineffective in treating your condition or is likely to be ineffective, or has caused or is likely to cause harm to you; or
- The number of doses available under a dose restriction has been or is likely to be ineffective in treating your condition.
If your drug is a non-preferred formulary drug (Tier 2 or Tier 4) and you believe it should be available for the preferred brand-name copay (Tier 1 or Tier 3), you or your doctor can request a Tiering Exception. Please note that a Tiering Exception is not available for specialty (Tier 5) drugs, nor can the exception process be used to get a brand-name drug (Tier 3 or Tier 4) for the generic (Tier 1 or Tier 2) copay. You may not request a Tiering Exception for a non-formulary drug that we have approved through the Formulary Exception Process.
Physician supporting statement for a tiering exception
In order for us to consider your request for a tiering exception, the prescribing physician must provide an oral or written supporting statement that the preferred (lower cost-sharing) drug(s) available for treatment of your condition would not be as effective for you as the requested drug and/or would have adverse effects for you.
Request an exception.
To request an exception or prior authorization, use the Medicare Part D Coverage Determination Request Form.
The prescribing doctor must sign the completed form and send it, with appropriate documentation of medical necessity, to:
Health Alliance Plan Attn: Pharmacy Care Management 2850 W. Grand Blvd. Detroit, MI 48202 Fax: (313) 664-8045
If approved, formulary exceptions will remain in effect until at least the end of the calendar year but may be approved up to 12 months. Tiering exceptions will remain in effect until the end of the calendar year (so long as your doctor continues to prescribe the drug and it continues to be considered safe and effective).
If we deny your request, you have the right to request an appeal.
To obtain an aggregate number of grievances, appeals and exceptions filed with the plan, contact us.
You may also refer to Chapter 7 or Chapter 9 in your Evidence of Coverage , titled: What to do if you have a problem or complaint (coverage decisions, appeals, complaints). If you prefer to contact Medicare, you can call (800) Medicare (800-633-4227) or TTY/TDD (877) 486-2048, 24 hours a day, seven days a week. Or you can file a complaint at the Medicare website (You are leaving a Medicare-approved site) . The Office of the Medicare Ombudsman (OMO) (You are leaving a Medicare-approved site) can help you.