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An exception request is a type of coverage determination. An enrollee, an enrollee's prescribing physician, or an enrollee's appointed representative may request a tiering exception, or a formulary exception. A tiering exception should be requested to obtain a non-preferred drug at the cost-sharing terms applicable to drugs in the preferred tier. A formulary exception should be requested to obtain a Part D drug that is not included on a plan sponsor's formulary. Exceptions requests are granted when a plan sponsor determines that a requested drug is medically necessary for an enrollee. Therefore, an enrollee's prescribing physician must submit a supporting statement to the plan sponsor supporting the request. For tiering exceptions, the physician's supporting statement must indicate that the preferred drug would not be as effective as the requested drug for treating the enrollee's condition, the preferred drug would have adverse effects for the enrollee, or both. For formulary exceptions, the physician's supporting statement must indicate that the non-formulary drug is necessary for treating an enrollee's condition because all covered Part D drugs on any tier would not be as effective or would have adverse effects, the number of doses under a dose restriction has been or is likely to be ineffective, or the alternative listed on the formulary or required to be used in accordance with step therapy has been or is likely to be ineffective. How to Submit a Supporting Statement A prescribing physician may submit his or her supporting statement to the plan sponsor orally or in writing. If submitted orally, the plan sponsor may require the physician to follow-up in writing. A physician may submit written supporting statements on the Model Coverage Determination Request Form for Physicians found in the "Downloads" section below, on an exceptions request form developed by a plan sponsor or other entity, or on any other written document (e.g., a letter) prepared by the physician. How a Plan Sponsor Processes an Exception Request Once a plan sponsor receives a physician's supporting statement, it must notify the enrollee of its coverage determination within 24 hours (for expedited requests) or 72 hours (for standard requests). If the plan sponsor's coverage determination is unfavorable, the decision will contain the information needed to file a request for redetermination with the plan sponsor.
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Page Last Modified: 08/31/2006 2:44:00 PM
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