If you have a medically necessary need for a non-formulary drug, you can ask us to make an exception and cover the drug. We respond to exception requests within 72 hours. There are three types of exceptions that you can ask for.
- Coverage for a drug, even if it is not on our drug list
- Waiving coverage restrictions or limits on a drug
- Lowering the tier cost of a drug
If we deny your exception request, we will mail you a letter explaining why your request was denied. This letter will include how you can appeal our decision. You can ask for a standard or expedited appeal.
New members have a 90-day transition period after they enroll in our plan. During this time, you can get a 30-day supply of your prescriptions that are not on our drug list, or that have step therapy or prior authorization requirements. After you get your 30-day supply, it is a good time to talk with your provider about a formulary exception or other drugs that may work for you.
If Customer Service confirms that we do not cover your drug, you can do the following:
- Ask your provider if you can switch to another drug that the plan covers. Call Customer Service if you need a list of covered drugs to share with your provider.
- Ask us to make an exception and cover your drug by completing our Request For Medicare Prescription Drug Coverage Determination (Solicitud de Determinacion de Cobertura de Medicamentos Recetados de Medicare)
- Using the Prescription Drug Coverage Determination form, you can also ask for an Expedited Exception (Expedited Decision). If you or your prescriber believe that waiting 72 hours for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 72 hours could seriously harm your health, we will automatically give you a decision within 24 hours. If you do not obtain your prescriber's support for an expedited request, we will decide if your case requires a fast decision. You cannot request an expedited coverage determination if you are asking us to pay you back for a drug you already received.
- Return this form by mail to CVS Caremark, P.O. Box 52000, MC109, Phoenix AZ 85072-2000, or by fax at 1-855-633-7673
You can also purchase your drug and ask for reimbursement by making an exception request.
Return the redetermination form by mail or fax as shown on the form.