Exceptions and Prior Authorization

What is an Exception?

An exception is a type of initial determination (also called a coverage determination) involving a Part D drug. You or your doctor may ask us to make an exception to our Part D coverage rules in a number of situations.

How do I request an exception to the Today's Health^® HMO 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. Excluded drugs cannot be covered by a Part D plan.
• You may ask us to waive coverage restrictions or limits on your Part D 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 and your doctor or other prescriber can ask the plan to make an exception in the cost-sharing tier (from non-preferred to preferred tier only) for the drug so that you pay less for the drug. If your doctor or other prescriber says that you have medical reasons that justify asking us for an exception, your doctor or other prescriber can help you request an exception to the rule.

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

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, 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 is valid for the remainder of the Plan year, so long as your doctor continues to prescribe the Part D drug for you and it continues to be safe for treating your condition. If we deny your exception request, you may appeal our decision.

Redetermination Notice

If you don't agree with the initial claim decision, you have the right to appeal your claim. This is called a redetermination and is the first level of the appeals process. Any dollar amount can be appealed at this level, but it needs to be submitted within 60 days from the date you received the initial claim decision.

To file a Redetermination request, you can send or fax the written request to us at:

• MAXIMUS
  1040 First Avenue, Suite 200
  King of Prussia, PA 19406
• Fax: 1-484-688-5601

You may also file a Redetermination request by phone. To file an appeal, or if you need information or help, call us at 1-800-958-2710 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-800-958-2692) every day.

What is a Prior Authorization?

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

Please refer to your Evidence of Coverage, sections on Exceptions and Prior Authorizations, for more information on what to do next.