Request an exception for a prescription or medical drug
You can call us or use a Medicare Part D coverage determination request form (PDF) to ask Priority Health to:
- Cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
- Cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.
- Waive coverage restrictions or limits on your drug. For example, for certain drugs, Priority Health Medicare limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.
- Cover a Part B medical drug. These are drugs you wouldn't usually give to yourself–like those you get at a doctor's office. Examples of drugs covered under Part B can include, but are not limited to:
- Drugs used with durable medical equipment
- Injectable and infused drugs
- Blood clotting factors
- Some oral end-stage renal disease drugs
To ask us to reimburse you for a covered prescription drug you paid for out of your pocket, use the Prescription expense reimbursement form (PDF).
Supporting statements from your doctor
If you are asking for a formulary, utilization management (prior authorization, step therapy, or quantity limit) or drug tier exception, you must have your doctor submit a supporting statement (see page 3 of the form) explaining the medical reasons why you should receive an exception. Your doctor may submit the supporting statement over the phone or in writing.
When you'll hear from us
Unless there are medical reasons for us to respond more quickly, we’ll generally make a decision within 72 hours of your request for a coverage determination or exception.
If your request to expedite is granted, after we get a supporting statement from your doctor or other prescriber we must give you a decision within 24 hours for Part D prescription drug and/or Part B medical drug coverage decisions.
If our coverage decision is in your favor
We must authorize the drug we agreed to provide. For prescription drug exceptions our approval is good for the remainder of the calendar year.
Filing an appeal if you are not happy with our decision
If you aren't satisfied with the coverage decision we make, you or your prescriber can ask us to reconsider. This is called "filing an appeal." Learn how.