Formulary Exception Process

Requesting a Formulary Exception

What if your drug is not on the formulary?

If your prescription is not listed on the formulary, you should first contact Member Services to see if it is covered. If it is not covered, you have three choices:

  1. You can ask your doctor if you can switch to another drug that is covered by us.
  2. You can ask us to make an exception for us to cover your drug.
  3. You can pay out-of-pocket for the drug and request the plan reimburse you by means of an exception request.

How can you request an exception to the Plan’s formulary?

You can ask us to make an exception to our coverage rules using the Request for Medicare Prescription Coverage Determination. In order for us to make a decision, your doctor must include supporting medical information. Have your doctor fax the exception request and supporting statement to our contracted pharmacy benefit manager, MedImpact, at (858) 790-7100.