Transition Policies & Exception Process

Transition Policies & Exception Process Section Banner Image

Transition Policies & Exceptions 

Please refer to the links below for information on Coventry's Exceptions, Step Therapy, and Transition Policies.





Transition Policies

Exceptions

What If My Drug Is Not On The Formulary?

If your prescription is not listed on our formulary, you should first contact Customer Service to be sure it is not covered. If Customer Service confirms that we do not cover your drug, you have three options:

  • Talk to your doctor(s) to decide if you should switch to a similar drug on our formulary that is used to treat the same medical conditions. 
  • You can ask us to make an exception and cover your drug. See “How Can I Request An Exception to the Formulary”?
  • You can pay out-of-pocket for the drug and request that the plan reimburse you. Unless it is an emergency, if you did not follow our exception process or the exception was not approved, your request for reimbursement may be denied. If we deny your request for reimbursement, you have the right to file an appeal. 

If you recently joined our plan and learn that we do not cover a drug you were taking when you joined our plan, you may be able to receive a one-time fill of that prescription. You can receive a one-time fill of the non-covered drug if one of the following applies:

  • You didn’t know that your drug wasn’t covered, or
  • You knew it wasn’t covered but you didn’t know that you could request an exception to the formulary.
  • After your one-time fill, we can help you identify similar drugs on our formulary that are used to treat the same medical condition. If we cannot find another drug for you, we will help you file a request for an exception to our formulary.
  • In some cases, we will contact you if you are taking a drug that is not on our formulary. We will let you know that your drug is not covered and help you identify similar drugs on our formulary that are used to treat the same medical condition.

How Can I Request An Exception to the Formulary?

You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

  • You can ask us to cover your drug even if it is not on our formulary.
  • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can 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 usually considered a Tier 3 drug, you can ask us to cover it as a Tier 2 drug instead. This would lower the copayment you must pay for your drug.
  • Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary or the low-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

In most circumstances, if we do approve your request for an exception, the exception is good for the rest of the year or the length of treatment approved.
 

Process for Filing an Exception

To request an exception, your prescribing physician may either call us or fax the request.  Access this form and additional information.

If this is an emergency, the pharmacy provider may enter an override code which will cover a 72 hour supply. Your prescribing physician may then call the clinical call center once it re-opens to request a long term exception.

If your physician requires an immediate response, the pharmacist will contact the on-call pharmacist who will respond to the prescriber as quickly as possible.

To request an exception, your prescribing physicians needs to provide the following information:

  • Your full name (First name and Last name)
  • Your Member ID number
  • Requested drug
  • Reason for the exception

An exception request form is available for your physician’s use.

Once an exception request is approved, it is valid for the remainder of the plan year or the length of therapy authorized so long as your physician continues to prescribe the drug for you and it continues to be safe and effective for treating your condition.

Step Therapy and Prior Authorization Process

Requesting Authorization

To request prior authorization (click here to access the form) or to place you in step therapy, prescribing physicians follow the exception process described above.

1. Call or fax us the request.

2. Provide the following information:

  • Your full name (First name and Last name)
  • Your Coventry Member ID number
  • Requested drug
  • Reason for the request


find a plan

Coventry Health Care offers products across the county. Compare and find the best plan for you.

Find 2014 Plans >>


Get Adobe Reader

Page Last Updated: 04/03/2014
CMS Approved Date: Approved 02/08/2013
CMS Document ID: Y0022_PDPCCP_2013_4006_1202b

© Copyright 2008-2014 Coventry Health Care

Coventry Health Care is a Coordinated Care plan with a Medicare contract. First Health Part D is a Medicare-approved Part D sponsor. Enrollment in our plans depends on contract renewal.