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Requesting Exceptions to What Is Covered

The information on this page is a summary of the full explanation and instructions in your plan's Evidence of Coverage booklet. For longer, more complete instructions, go to:


Requesting an Exception to the Approved Drug List or to What's Covered by Your Plan

You or your authorized representative can ask us to:
  • Cover a drug that is not on our formulary (approved drug list) (generally, we will only approve your request if the drugs on the formulary would not be as effective in treating your condition, and/or if they would cause you more health problems)
  • Give you an exception if the drug your doctor wants you to take first requires step therapy (trying other things first) or quantity limits
  • Give you an exception if the service your doctor wants you to have is not covered by your PriorityMedicareSM plan
You will need a statement from your doctor supporting your request.

What to do to request an initial decision:

  1. Ask your doctor to write a statement supporting your request. He or she should use a Coverage Determination Request Form (237KB PDF).
  2. Call Customer Service to ask for an "initial coverage decision" (you don't need to put your request in writing, but you can use the federal government's Coverage Determination Request Form if you wish).
  3. Customer Service will explain how to submit the statement from your doctor, and your request if in writing, to us by fax or by mail.
We will generally make a decision within 72 hours of your request. If you are granted an exception, it will usually be good for the rest of the calendar year.

If you are not satisfied with the initial decision:
You can ask us to reconsider our initial decision not to make an exception. This is called "filing an appeal."
Go to instructions for filing an appeal

Learn how to name an authorized representative to act for you.



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H2320_4000_4006_59 (09/06) and S5857_4000_4006_59 (09/06)
Last modified 12/23/08