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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 on a different tier than what your plan covers.
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.
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:
If your drug is a nonpreferred 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 isn’t 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 nonformulary drug that we have approved through the formulary exception process.
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.
To request an exception or prior authorization, use the Medicare Part D Coverage Determination Request 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).
To obtain an aggregate number of grievances, appeals and exceptions filed with the plan, contact us.
Copyright © 2017 HAP
2017 Health Alliance Plan of Michigan
Y0076_ALL_2018029 Website MP
CMS Approved: 6/26/2017
Last Update: 6/21/2017
HAP Senior Plus® HMO, HMO-POS, and PPO are health plans with a Medicare contract. Enrollment in these plans depends on contract renewal. HAP Senior Plus® PPO is a product of Alliance Health and Life Insurance Company, a wholly owned subsidiary of HAP. Alliance Medicare Supplement is a product of Alliance Health and Life Insurance Company, a wholly owned subsidiary of HAP.
This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
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