Exceptions and Prior Authorizations

What is a Prior Authorization?

Today's Options^® HMO requires you to get prior authorization for certain medicines. This means that you will need to get approval from your plan before you fill your prescription. If you don't get approval, Today's Options HMO may not cover the medicine.

What is a coverage determination?

A coverage determination is a decision we make about your benefits and/or coverage or about the amount we will pay for your prescription drugs. Here are examples of coverage determinations you can ask us to make about your Part D drugs:

• You can ask us whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on our formulary but we require you to get approval from us before we will cover it for you.)
• You can ask us to pay for a prescription drug you already bought.
• You can ask us to make an exception to our formulary.

What is an Exception?

An exception is a type of coverage decision. You or your doctor may ask us to make an exception to our formulary. As our member, you have the right to request several types of exceptions, including:

• You may ask us to cover your Part D drug even if it is not on our formulary.
• You may ask us to waive a restriction on our coverage of a drug. For example, for certain Part D drugs, we limit the amount of the drug that we will cover. If your Part D drug has a quantity limit, you may ask us to waive the limit and cover more.
• You can ask us to provide a higher level of coverage for your drug. For example, if your drug is contained in our Tier 3, you can ask us to cover it at the cost-sharing amount that applies to drugs in Tier 2 instead. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in Tier 2 (Preferred Brand Drugs) or in Tier 4 (Specialty Tier).

How do I request an exception to the Today's Options HMO formulary?

You should contact us to ask for an initial coverage determination for a formulary exception. Your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception. Your doctor can submit a statement using a request form - available by using our Drug Search tool. For a faster decision, include this information from your doctor or other prescriber when you ask for the exception.

Generally, we will only approve your request for an exception if the alternative drugs included on our formulary, the drug in the preferred tier, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

We must make our decision within 72 hours of getting your prescribing physician's supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician's supporting statement.

If we approve your exception request, our approval usually is valid until the end of the Plan year, so long as your doctor or other prescriber continues to prescribe the Part D drug for you and it continues to be safe and effective for treating your condition. If we deny your exception request, you can ask for a review of our decision by making an appeal.

To file a standard request, you can send the request to us in writing at:

• Appeals and Coverage Determination
  PO Box 391197
  Solon, OH 44139-3911
  Toll Free Fax: 1-866-868-0858

You may also file a request by phone. To file a request, or to request more information or assistance, call us at 1-866-316-6049, 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-866-684-5351) 7 days a week.