Asking for an exception
We expect that the drugs on the Approved Drug List (formulary) for your plan will meet all your prescription drug needs. However, if your doctor prescribes a drug that's not on your plan's Approved Drug List, we may still approve it for you.
Here's the process for asking for an exception to the formulary:
- Your doctor will fill out a drug authorization request form that explains why you need the non-formulary drug.
- Priority Health will let you and your doctor know, within 24 hours of receiving all information we need to make a decision, whether or not we approve the drug for you.
- If you are not happy with the determination, you or your representative have the right to request a decision by an Independent Review Organization (IRO).
- Priority Health has 72 hours to get an IRO decision, or 24 hours to get an IRO decision if waiting 72 hours may seriously jeopardize your life or health or your ability to regain maximum function or when you are undergoing a current course of treatment using a non-formulary drug. Priority Health will cover the non-formulary drug during the review period and for as long as required by law.