What if your drug is not on the formulary?

If your prescription is not listed on the formulary, you should first contact Customer Service to verify that it is not covered.

Call 1-888-494-2583 or TTY/TDD 1-800-377-1363.  Hours are 8:00 a.m. to 8:00 p.m., seven days a week.

Within the first 90 days of joining the plan you may request a one-time fill of a non-formulary drug.  After your one-time fill we will send you a list of formulary drugs covered to treat your medical condition.  You can ask your doctor if this drug is an option for your treatment.  You can also file a request for an exception (which is a type of coverage determination).to our formulary.

If Customer Service confirms that we do not cover your drug, you have three options:

1. You can ask your doctor if you can switch to another drug that is covered by us. If you would like to give your doctor a list of covered drugs that are used to treat similar medical conditions, please contact Customer Service.
   
2. You can ask us to make an exception (which is a type of coverage determination) for us to cover your drug. Prescription Drug Coverage Determination.
   

You can pay for the drug and request that the plan reimburse you by means of an exceptions request (which is a type of coverage determination). This does not obligate the plan to reimburse you if the exception request is not approved. If the exception is not approved, you may appeal the plan's denial.   Prescription Drug Coverage Redetermination.

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