Prior Authorization

NON-FORMULARY DRUGS

Members requesting non-formulary drugs must work with their Provider to get an exception granted from VHP.

A member can ask for a drug that is not on the formulary by requesting a Prescription Drug Prior Authorization or Step Therapy Exception Request to be sent to the Provider by:

The prescriber must completely fill out the Prescription Drug Prior Authorization or Step Therapy Exception Request form with information that supports the request for a drug not on the formulary and submit it to the PBM. The form will be reviewed and approved based on established medical criteria and/or medical necessity and the member and provider will receive communication with the decision.

  • ​The Prescription Drug Prior Authorization or Step Therapy Exception Request form request will be turned around within 72 hours for non-urgent requests, and within 24 hours if exigent circumstances exist, upon receipt of a completed prior authorization request from a prescribing provider.
  • ​“Exigent circumstances” exist when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee’s life, health, or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a nonformulary drug.

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