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 formulary and submit
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 nonurgent 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.