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Small Employer Group Plans: SimplyBlue Plus Bronze, Silver, Gold or Platinum
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If you want to request coverage of a drug not on our formulary, a waiver of our utilization management requirements or your cost-sharing amount, you can request an exception.
Call our Customer Service Department to request an exception to our coverage rules.
What is an exception?
An exception is a type of initial determination (also called a "coverage determination") involving a drug. You, your doctor or other prescriber may ask us to make an exception to our coverage rules in a number of situations.
You may ask us to cover your drug even if it is not on our formulary. Excluded drugs cannot be covered by a plan unless coverage is through an enhanced plan that covers those excluded drugs.
You may ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you may ask us to waive the limit and cover more.
You may ask us to provide a higher level of coverage for your drug. If your drug is contained in our non-preferred tier (Tier 3), you may ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier (Tier 2) subject to the tiering exceptions process. This would lower the coinsurance/co-payment amount you must pay for your drug. 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 the tier designated as the high cost specialty generic and brand drug tier (Tier 3).
Your doctor must submit a statement supporting your exception request. In order to help us make a decision more quickly, the supporting medical information from your doctor should be sent to us with the exception request.
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 drug for you and it continues to be safe for treating your condition. If we deny your exception request, you may appeal our decision.
Your doctor may if they choose, request prior authorization for you using these forms.