Resources for navigators and assisters

Medical exceptions

In certain cases, you or your prescriber can request a medical exception to the precertification, step therapy or quantity limits requirements or for a drug that’s not covered on your plan. This can be requested on or after the effective date of your coverage. Standard coverage decisions will be made within 72 hours of the initial request. You can ask for your request to be expedited. Expedited coverage decisions are made within 24 hours. We’ll then contact you or your prescriber with our decision. All medically necessary outpatient prescription drugs will be covered. If a medical exception is approved, you will only need to pay the copay after your deductible, if any, is met. This amount is based on your pharmacy plan design.

To submit a medical exception request for a noncovered drug, providers have these options:

• Submit their request through our secure provider website on www.availity.com.
• Call the Pharmacy Precertification Unit: Non-Specialty 1-800-294-5979 (TTY: 711) or Specialty 1-866-814-5506 (TTY: 711).
• Fax the completed request form to: Non-Specialty 1-888-836-0730 or Specialty 1-866-249-6155.
• Mail the completed request form to: Medical Exception to Pharmacy Prior Authorization Unit 1300 East Campbell Road Richardson, TX 75081

Under health care reform, you can get some drugs and products with no member cost share. This means they are covered 100 percent by your plan. This list shows some common examples.

Preventive drugs and products - 2023 (PDF)