If your prescription isn’t listed on the formulary, you should first contact Customer Service to be sure it isn’t covered.
If Customer Service confirms that we don’t cover your drug, you have three options:
You may ask your doctor if you can switch to another drug that is covered by us.
You may ask us to make an exception (which is a type of coverage determination) to cover your drug. See your Evidence of Coverage (member handbook) to learn more about how to request an exception.
You can pay out-of-pocket for the drug and request that the Plan reimburse you by requesting an exception (which is a type of coverage determination). This doesn’t obligate the Plan to reimburse you if the exception request isn’t approved. If the exception isn’t approved, you may appeal the Plan’s denial. Please see your Evidence of Coverage for more information on how to request an appeal.
In some cases, we will contact you if you are taking a drug that isn’t on our formulary. We can give you the names of covered drugs that also are used to treat your condition so you can ask your doctor if any of these drugs are an option for your treatment.