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 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.

Expedited decisions

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.