Part D Exceptions

You can ask us to make the following exceptions to our coverage rules: You can ask us to remove a coverage restriction or limit on your drug. This is called a Formulary Exception. For example, CHP limits the amount of certain drugs that we will cover; this is called a "quantity limit." If your drug has a quantity limit, you can ask us to remove the limit and cover more. In some cases, CHP requires that you first try one drug to treat a medical condition before we will cover another drug for that condition. This is called "step therapy." You can ask us to remove a step therapy requirement.

You can ask us to cover a Part D drug that is not on the CHP Formulary. This is called a Formulary Exception. Generally, a non-formulary drug is covered only if the alternative drug listed on the formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You can ask us to provide a higher level of coverage for your drug. This is called a Tiering Exception. For example, if your drug is a Tier 3 drug, you can ask us to cover it as a Tier 2 drug instead. This would lower the copayment/ coinsurance amount that you would pay for the drug. (There are limitations to this type of request. You cannot request a change to the coinsurance on a Tier 4 drug. You cannot request a change from a Tier 2 copayment to a generic copayment nor a change from a Tier 3 copayment to a generic copayment.)

Your doctor or other prescriber must submit a statement and supporting information about the medical need for the exception. (A form is available for your doctor or other prescriber to use, although using the form is not required: Medicare Part D Coverage Determination Request Form (pdf 259.65 kB) [PDF].)

A request for an exception will be approved only when there is a medical reason for it.

You, your appointed representative, or your doctor pr other prescriber may request an exception by calling us at one of the telephone numbers listed on this page or writing us at the address listed on this page. (A form is available for you to use, although using the form is not required: Request For Medicare Prescription Drug Coverage Determination (pdf 31.27 kB) [PDF].)

Capital Health Plan will notify you and your doctor or other prescriber of our decision about a standard request for an exception as quickly as your health condition requires, but no later than 72 hours after we receive the required information from your doctor or other prescriber. Our notification will be given within 24 hours after we receive the required information from your doctor or other prescriber if he or she indicates that waiting for a standard determination seriously could harm your health or your ability to function. If your doctor or other prescriber does not provide us with the required information, we will wait up to 45 days before we make our decision. If your doctor or other prescriber does not provide the requested information within 45 days, we will make our decision with the information that we have.

If we receive the supporting statement from your doctor or other prescriber and we do not provide a timely response, your request automatically is sent to the Independent Review Organization for review.

Request for a Formulary Exception

You can make requests for an exception for drugs that have coverage restrictions, including quantity limits, step therapy requirements, and prior authorization.

Your doctor or other prescriber must give Capital Health Plan information that the requested drug is more effective in treating your disease or condition or the restricted quantity is likely to be ineffective or adversely affect your compliance. The request from the doctor or other prescriber must be supported by sound clinical evidence and scientific literature. A Medical Director will review the request and the information provided by your doctor or other prescriber. The fact that your doctor or other prescriber submits a statement supporting your request does not mean that you automatically will receive approval of your request.

If the exception is approved, arrangements will be made to cover the requested drug or quantities of the drug and you will be notified of the approval. You will not have to request a new approval before the end of the plan year as long as your doctor or other prescriber continues to prescribe the drug for your condition; the drug continues to be safe for treating your condition, and you remain enrolled in our plan. If you renew your membership in CHP's Medicare program, CHP may continue to cover the drug into the new plan year.

If the exception is denied, you will be notified of the decision and given information about your appeal rights.

Request for a Tiering Exception

Your doctor or other prescriber must give Capital Health Plan information that the drug that you want at a lower copayment is more effective than the original drug or that the original drug has negative effects, or both. A Medical Director will review the request and the information provided by your doctor or other prescriber. The fact that your doctor or other subscriber submits a statement supporting your request does not mean that you automatically will receive approval of your request.

If the exception is approved, arrangements will be made to cover the requested drug at the Tier 2 copayment and you will be notified of the approval. You will not have to request a new approval before the end of the plan year as long as your doctor or other prescriber continues to prescribe the requested drug for your condition, the requested drug continues to be safe for treating your condition, and you remain enrolled in our plan. If you renew your membership in CHP's Medicare program, CHP may continue to cover the drug into the new plan year.

If the exception is denied, you will be notified of the decision and given information about your appeal rights. Please review your Evidence of Coverage for more information about the Part D exceptions process.