Formulary exception
A request for coverage of a non-formulary drug, supported by a prescriber statement of medical necessity.
A formulary exception is the formal process for getting your plan to cover a drug that isn't on its formulary, or to cover a higher-tier drug at a lower-tier cost. The prescriber submits a statement explaining why formulary alternatives are clinically inappropriate — allergy, intolerance, contraindication, prior failure of formulary drugs, or inferior efficacy expected. Approved exceptions typically remain in effect for the plan year.
Frequently asked questions
What is formulary exception?
A formulary exception is the formal process for getting your plan to cover a drug that isn't on its formulary, or to cover a higher-tier drug at a lower-tier cost. The prescriber submits a statement explaining why formulary alternatives are clinically inappropriate — allergy, intolerance, contraindication, prior failure of formulary drugs, or inferior efficacy expected. Approved exceptions typically remain in effect for the plan year.
Related terms
- FormularyThe list of prescription drugs your plan covers, organized into tiers with different cost-sharing.
- Non-formulary drugA drug not included on your plan's covered drug list. Requires a formulary exception request for cov
- Step therapyA plan requirement to try and fail a cheaper drug before the plan covers the requested drug.
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