Medication exception/drug coverage determination

Medication exception / drug 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. (Premier and Premier Plus only)

To request an exception, you, your authorized representative, or the prescribing physician have two options:

Mail:
Samaritan Advantage Health Plan HMO
P.O. Box M
Corvallis, OR 97339
Fax:
1-877-502-9254







You can find the standard Medicare forms for patients and physicians by clicking on the link below. By clicking on this link, you will be directed to an external website:
http://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/CoverageDeterminationsandExceptions.html.

E X P E D I T E D  R E Q U E S T S
For expedited requests, you or the prescribing physician may call Customer Service at (541) 768-4550 or 1-800-832-4580, from 8 a.m. to 8 p.m. TTY users should call
1-800-735-2900.

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. For drugs with a Part B versus D administrative prior authorization requirement: This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.


Extra help for prescription drug costs

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778; or your State Medicaid office.

In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances. Quantity limitations and restrictions may apply.


Last modified: January 16, 2014
H3811_MA4001_2013F CMS Approved 01/21/2014