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.
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:
- For approval of a non-formulary drug, there must be a treatment failure after an adequate trial of at least four (4) formulary drugs from the same therapeutic class as the requested drug. If four drugs with a similar mechanism of action are not available on the formulary, a trial of alternative formulary drugs that are acceptable to treat the member's condition is required, as clinically appropriate. For DAW requests, a treatment failure after an adequate trial of all formulary drugs in the same therapeutic class as well as other classes that can be used to treat the member's medical condition, as clinically appropriate is required. Members must have a documented allergy or adverse event to one or more ingredients present in the generic formulation and that are absent in the brand.
- 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.
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).
Note: A member is prohibited from requesting a tiering exception for a non-formulary drug approved under the formulary exception process. 42 CFR § 423.578(c)(4)(iii)
If we deny your request, you have the right to request an appeal.