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Obtaining a Formulary Exception or Reimbursement

You can ask Health Partners Medicare to make an exception to our coverage rules. There are several types of exceptions that you can request:

  • You can ask us to cover a drug that is not on our formulary. If approved, this drug will be covered at a predetermined cost-sharing level. You will not be able to ask us to provide the drug at a lower cost-sharing level.
  • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit
  • You can ask us to cover a formulary drug at a lower cost-sharing level. If your drug is in the Generic tier, you can ask us to cover it at a lower cost-sharing amount that applies to drugs in the Preferred Generic tier. If your drug is in the Non-Preferred Drug tier, you can ask us to cover it at a lower cost-sharing amount that applies to drugs in the Preferred Brand tier. If approved, you will pay less for that drug. You cannot ask us to change the cost-sharing tier for any drug in the Specialty tier.

    Generally, Health Partners Medicare will only approve your request for a tiering exception if the alternative drug is included in the plan’s formulary, or if the drug with lower cost-sharing or additional utilization restrictions would not be as effective in treating your condition, and/or would cause you to have adverse medical effects.

How do I request an exception to the Health Partners Medicare Formulary?

You, your prescriber, or your representative can request an exception. If you request an exception, we may need a statement from your prescriber supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your prescriber believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your prescriber.

To request an initial coverage decision for a formulary, tiering or utilization restriction exception, contact us at 1-866-901-8000 (TTY 711) or by fax at 1-866-371-3239.

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