Common use of Exceptions to Coverage Clause in Contracts

Exceptions to Coverage. Health Options has a process for allowing exceptions to our formulary. To obtain coverage consideration for a drug not on our formulary, you, your Designee, or the prescribing Provider must submit a request to Health Options’ PBM with a clinical rationale for the exception. Our PBM or Medical Benefit Manager (MBM) will make a decision within 48 hours, or in exigent circumstances, within 24 hours, upon receipt of all required information. Exigent circumstances exist when you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, or when you are undergoing a current course of treatment using a non-formulary drug. A prescription that requires an exception for coverage shall be considered approved up to 30 calendar days if the exception process exceeds 48 hours from the receipt of all necessary information. In the case of exigent circumstances, if the request for coverage is approved, coverage for the drug will be available for the duration of the exigency. If the request for coverage is approved, the drug will be covered as a Tier 4 drug (cost-sharing will apply as listed in the Schedule of Benefits), and the prescription will be considered a Covered Service. You, your Designee, or the prescribing Provider may request an accredited independent review organization review the denial of an exception request. If you or your Designee are requesting the exception, you will need to provide the prescribing Provider’s information so our PBM can contact the prescribing Provider to obtain information to support the request.