Request an exception for a prescription drug
You can call us or use a Medicare Part D Coverage Determination Request Form (PDF) to ask Priority Health to:
- Make an exception and cover a drug that is not on the formulary
- Ask for authorization for a drug your doctor has prescribed, if the drug requires prior authorization
- Ask to be excepted from the requirements that you try another drug first (step therapy requirements)
- Request an exception to the quantity limit on a drug
- Ask to be reimbursed for a covered prescription drug you paid for out of your pocket
- Ask to keep paying a lower tier copayment, if your drug has been moved to a higher tier
- Ask to pay a lower tier copayment for the drug your prescriber prescribed, if that drug's copayment is higher than other drugs that treat your condition
Supporting statements from your doctor
If you are asking for a formulary, utilization management (prior authorization, step therapy, or quantity limit), or copayment coverage decision, 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 prescription drug coverage decision.
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 prescription drug coverage decisions.
If our exception is in your favor, we must authorize the drug we agreed to provide. For prescription drug exceptions our approval is usually good for the rest of the calendar year.
If our coverage decision is in your favor
We must authorize the drug or medical service we agreed to provide. For prescription drug exceptions our approval is usually good for the rest 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 can ask us to reconsider. This is called "filing an appeal."