Formulary Exception Process Clause Samples
The Formulary Exception Process clause outlines the procedure by which a patient or healthcare provider can request coverage for a medication not included on a health plan’s standard formulary. Typically, this process requires submission of supporting medical documentation to justify the need for the non-formulary drug, and the insurer must review and respond to the request within a specified timeframe. This clause ensures that patients have a formal avenue to access necessary medications that are otherwise excluded, addressing situations where standard formulary options are insufficient or inappropriate for individual medical needs.
Formulary Exception Process. We have a formulary exception process that allows you to request coverage for a prescription drug that is not in our formulary. This process is available when:
Formulary Exception Process. We have a formulary exception process that allows you to request coverage for a prescription drug that is not in our formulary. This process is available when (i) the requested prescription drug is NOT a generic equivalent of a formulary drug and your doctor determines that a formulary drug is not effective for you; or (ii) the requested non-formulary prescription drug has a generic equivalent and you have a clinical reason why you are unable to take the generic prescription drug (such as, you have had an adverse reaction to the generic medication). The process for obtaining an exception is described below. For a formulary exception where the requested prescription drug is NOT a generic equivalent of a formulary drug the prescribing provider may obtain a Medical Exception Form by visiting our Web site at ▇▇▇▇▇▇.▇▇▇ or calling the Physician and Provider Service Center. Requests may be submitted in one of the following ways: by fax: submit the form to Catamaran at ▇-▇▇▇-▇▇▇-▇▇▇▇; by phone: contact Catamaran at ▇-▇▇▇-▇▇▇-▇▇▇▇; or by mail: send the completed form to: Catamaran Prior Authorization
Formulary Exception Process. We have a formulary exception process that allows you to request coverage for a prescription drug that is not in our formulary. This process is available when (i) the requested prescription drug is NOT a generic equivalent of a formulary drug and your doctor determines that a formulary drug is not effective for you; or (ii) the requested non-formulary prescription drug has a generic equivalent and you have a clinical reason why you are unable to take the generic prescription drug (such as, you have had an adverse reaction to the generic medication). The process for obtaining an exception is described below.