Medication exception / coverage determination
You can ask us to make a medication exception to our coverage rules if you are a member of one of our plans that offer prescription drug coverage: the Samaritan Advantage Premier, Premier Plus, and Special Needs Plans (HMO). This includes exceptions for:
- Covering your drug even if it is not on our formulary.
- Waiving coverage restrictions or limits on your drug.
- Providing a higher level of coverage for your drug.
To request an exception, you or the prescribing physician will need to complete our form and mail, fax or drop by our office. Download Samaritan Health Plans form. For expedited requests, you or the prescribing physician may call Customer Service.
You can find the standard Medicare forms for patients and physicians at the link below.
http://www.cms.hhs.gov/medprescriptdrugapplgriev/13_forms.asp
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. 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 order to help us make a decision more quickly, you should include supporting medical information from your doctor when you submit your medication exception request. If we approve your medication 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 and effective for treating your condition. If we deny your medication exception request, you can appeal our decision.
See also Member Resources for the Evidence of Coverage for specific details.
Last modified: October 1, 2009
H3811_MA4001 CMS approved 11.2009