Drug Exception Process
Note: Drugs that CMS does not recognize as a Part D Covered benefit is not eligible for this program.
MedicarePlus has an Exception Process for members applicable to situations where a Part D medication is subject to a Coverage Determination. An enrollee, an enrollee's prescriber, or an enrollee's representative may request a tiering exception or a formulary exception.
- A tiering exception should be requested to obtain a non-preferred drug at the lower cost-sharing terms applicable to drugs in a preferred tier. Specialty Tier drugs, Tier 5, are not subject to the tiering exception.
- A formulary exception should be requested to obtain a Part D drug that is not included on a plan sponsor's formulary, or to obtain a formulary drug that is subject to a utilization management restriction (e.g., step therapy, prior authorization, quantity limit) which the enrollee or the enrollee’s prescriber believes should not apply.
Exceptions requests are granted when MedicarePlus determines that a requested drug is medically necessary for an enrollee. Therefore, an enrollee's prescriber must submit a supporting statement to the MedicarePlus supporting the request.
- For tiering exceptions, the prescriber's supporting statement must indicate that the preferred drug(s) would not be as effective as the requested drug for treating the enrollee's condition, the preferred drug(s) would have adverse effects for the enrollee, or both.
- For formulary exceptions, the prescriber's supporting statement must indicate that the non-formulary drug is necessary for treating an enrollee's condition because all covered Part D drugs on any tier would not be as effective or would have adverse effects, the number of doses under a dose restriction has been or is likely to be less effective, or the alternative(s) listed on the formulary or required to be used in accordance with step therapy has(have) been or is(are) likely to be less effective or have adverse effects.
How MedicarePlus processes an exception request
For requests for benefits, once MedicarePlus receives a prescriber's supporting statement, we will provide a written notice of our decision within 24 hours (for expedited requests) or 72 hours (for standard requests). The initial notice may be provided orally with a written follow-up notice mailed to the enrollee within 3 calendar days of the oral notification.
For requests for payment that involve exceptions, MedicarePlus will provide notice of its decision (and make payment when appropriate) within 14 calendar days after receiving a request.
If the MedicarePlus’ coverage determination is unfavorable, the decision will contain the information needed to file a request for redetermination with MedicarePlus.
To access the exception process, the provider, member or member’s representative can submit an online Request for Coverage Determination, or the provider can complete a Prescription Drug Determination Form (PDF) and indicate the desired action on the form (e.g., utilization management exception). MedicarePlus will process all exception requests as standard unless the provider specifies expedited processing. The completed request should be sent to the HealthPlus Pharmacy Department by fax, mail, or phone seven days per week, from 8 a.m. to 8 p.m. at:
HealthPlus of Michigan, Inc.
Attn: Pharmacy Operations
2050 S. Linden Rd.
Flint, MI 48532-4199
If a decision could not be reached through the MedicarePlus exception process, the request for processing coverage determinations (including exception requests) and redeterminations will be forwarded to an Independent Review Entity* (IRE) within 24 hours of the expiration of the appropriate adjudication timeframe. IRE is an independent review organization that has a contract with the federal government and is not part of HealthPlus MedicarePlus. MPRO is the MedicarePlus designated Medicare IRE.
The member can use an out of network pharmacy, if the need arises. If the request is denied, the member or provider may request a re-determination. On the rare occasion that the physician or member is not satisfied with the outcome of the exception process, MedicarePlus has an appeals and grievance process for MedicarePlus members.
While MedicarePlus may grant an exception request based upon documented failure of alternative medications, MedicarePlus may also grant a request when there is sufficient evidence that alternative medications would not be as effective or would have adverse effects for the member. MedicarePlus would not deny a request based solely on the absence of documented trial of alternative medications.
In reference to prescription drug dose restriction, MedicarePlus may grant an exception request based upon ineffectiveness or adverse outcome due to dose limitations. MedicarePlus may also grant a request when there is sufficient evidence that dose limitations would not be as effective or would have adverse effects for the member. Approved non-formulary drugs will be assigned to tier 4. MedicarePlus’ exception process does not restrict the number of exception requests submitted per member.