Common use of Formulary Exceptions Clause in Contracts

Formulary Exceptions. Your provider may have prescribed a Prescription Drug that is not on our Formulary, or that has special coverage rules or requirements in order to be covered by this plan. If you require a Prescription Drug that is not covered in the way you or your provider would like it to be, you may request an exception. To request a Formulary Exception you or your provider must call or submit your request in writing to: Express Scripts, Inc. Attn: Prior Authorization Mail Stop B401-03 0000 Xxxxx Xxxx St. Louis, MO 63134 Phone: 0-000-000-0000 After your request for a Formulary Exception has been reviewed, you will receive written notification of our decision to approve or deny your request. For standard formulary exception requests we will issue a decision and notify the enrollee or enrollee’s agent and the enrollee’s prescriber within 72 hours of receipt of receiving the initial request. For expedited formulary exception requests we will issue a decision and notify the enrollee or enrollee’s agent and the enrollee’s prescriber within 24 hours of receipt of the initial request. If your request is denied, this plan will not cover the requested drug, and you will be responsible for any costs associated with the requested drug. If you do not agree with the plan’s determination, you have the right to appeal our decision, or to seek external review through an Independent Review Organization (“IRO”). See the Appeals section of this Agreement for information about seeking external review or filing an Appeal.