An exception is a special request for a plan to cover something outside of its usual coverage policies. For prescription drug benefits, an exception request can apply in a number of situations:
- A drug that you need is not on the plan’s formulary.
- You or your prescriber feel that you cannot meet the plan’s coverage rules or requirements for the drug you need.
- The lower tier drug on the plan’s formulary is not appropriate for you, and you would like the plan to cover the higher tier drug at the lower cost sharing amount.