What If My Drug Is Not On The Formulary?

If your prescription is not listed on our formulary, you should first contact Customer Service (click here for contact information) 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 co-payment 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.  Click here to access this form and for 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.

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

Transition Policy for New Members

1. If your medication is currently covered on one of the formulary copay tiers, then there is no action needed.

2. Quantity Limitations:

For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time. For example, we will provide up to 4 units per prescription for FOSAMAX per 30 days. If the medication is listed on the Quantity Level Limitations (QLL) Lists, then there is no action needed.

• Medications on the QLL are identified as once daily drugs (i.e. Zocor 20mg) or
• Medications commercially packaged (i.e. inhalers, tubes, patches) or
• Medications package insert states specific dosing (i.e. Fosamax Weekly)

3. Prior Authorization:

In some cases, we require you to get Prior Authorization for certain drugs. This means that you will need to get approval from us before you fill your prescription. If you don’t get prior approval, we may not cover the drug. In other cases, we may require you to first try one drug to treat your medical condition before we will cover another drug for that condition. This is called Step Therapy. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, our plan will then cover Drug B. For those medications listed on the Prior Authorization (PA) and Step Therapy (ST) Lists, the pharmacy system will automatically allow a “first fill” without action needed by the provider.

• An automatic temporary “first fill” supply of 31 days will be dispensed so you are stabilized during the transition and will allow you sufficient time to contact your prescribing physician “prescriber” so that the prescriber may request approval if treatment is necessary beyond the “first fill” supply.
• After the 31 day first fill, you and your prescribing physician, will be required to follow the normal process for requesting prior authorizations and medical necessity review, step therapy, or exception processing.
• Decisions on transitions will appropriately address situations involving your need to be stabilized on drugs that are not on the Plan’s formulary and have known risks associated with any changes in the prescribed regimen.
   

4. Long Term Care (LTC) enrollees/residents:

Long Term Care (LTC) enrollees/residents will automatically receive a temporary “first fill” supply of 31 days. Because of the complexities associated with the coordination of care for residents in LTC facilities, we will grant an extension of the temporary “first fill” to include a total of up to 90 days depending on the circumstances and when requested.

• After the 31 day “first fill”, you and your prescribing physician will be required to follow the normal process for requesting prior authorizations and medical necessity review, step therapy, or exception processing.
• Decisions on transitions will appropriately address situations involving your need to be stabilized on drugs that are not on the Plan’s formulary and have known risks associated with any changes in the prescribed regimen.
• An emergency supply of medication for Long Term Care residents will be covered as follows:
  o As per the policy described above, under the “first fill” supply of 31 days without action needed by the provider.
  o If the above “first fill” policy is not applicable or appropriate, then an emergency supply of three (3) days will be granted upon request.

Transition for Existing Members

This applies to currently enrolled members past the initial transition period of 30 days (see process outlined above)

1. Annual changes to the tiers of medication.

• Should a medication you are currently taking be removed from the formulary, you and your prescribing physician will receive a letter informing them of the changes taking place sixty (60) days prior to the effective date. During this 60-day period, the enrollee will be able to obtain the medication at the pre-existing copay tier.

2. Non-annual changes to medications may occur.

• If a medication is removed from the market, you and your physician will be notified, along with the therapeutically equivalent substitution on the same tier if applicable.
• If a Part D medication is currently covered and receives a new FDA indication, the P&T Committee may change it to a different copay tier and/or require prior authorization and/or stepped therapy.
• If a Part D medication is deemed to be unsafe.
• You and your prescribing physician will be notified of these non-annual changes as soon as possible. Depending on the change, a 60-day period of transition may not be possible or appropriate. The notice to the you and your physician will describe the specific transition process.
   

3. Level of care changes

• Unplanned transitions for current enrollees could arise where prescribed drugs are not on the Plan’s formulary. For example, if you enter a long term care (LTC) facilities from a hospital or are discharged home from a hospital. For these unplanned transitions, you and your provider need to utilize the Plan’s exception and appeals process should the drugs not be on the Plan’s formulary.