Exceptions

We may be able to cover medications outside your plan restrictions

In some cases, it may be possible to receive an exception for nonformulary or nonpreferred formulary drugs. These are drugs not on our drug list (formulary) or are in a tier that is higher than you feel is appropriate.

Formulary exceptions

If a drug your doctor prescribes isn’t on our drug list, 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 nonformulary drug we approve through the formulary exception process will be considered a nonpreferred generic (Tier 2) or non-preferred brand (Tier 4) drug.

Doctor’s 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 drug is medically necessary to treat your condition. The doctor may provide one or more of these reasons why you need an exception:

• At least two of the covered drugs on any tier of the drug list available for treatment of your condition would not be as effective as the nonformulary drug and/or would be harmful for you.
• The prescription drug alternatives on the formulary or required to be used in accordance with step therapy requirements have been ineffective or have caused or are likely to cause you harm.
• The number of doses available under a dose restriction have been or are likely to be ineffective in treating your condition.

Tiering exceptions

If your drug is in tiers 2, 3, or 4 and you believe it should be available in a lower tier, you or your doctor can request a tiering exception.

Please note that a tiering exception isn’t available for specialty (Tier 5) drugs.

You may not request a tiering exception for a nonformulary 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 as the requested drug and/or would have adverse effects for you.

Request an exception

To request an exception or prior authorization, use the Request for Medicare Prescription Drug Coverage Determination form (PDF).

The prescribing doctor must sign the completed form and send it, with appropriate documentation of medical necessity, to us at the address below:

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 for 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.