Authorizations, Limits, and Exceptions
Some of the prescription drugs we cover have “restrictions” on when or how you can get them. These restrictions are called Prior Authorization, Quantity Limits, and Step Therapy.
You can look up your medicines on our Healthfirst formulary to see if they have any of these restrictions.
What do these restrictions mean?
- Prior Authorization means that your doctor will need to provide extra information to us before we will cover your medicine. In some cases, we may not cover the drug.
- Quantity Limits means that there is a limit to how much of the medicine we will cover.
- Step Therapy means we may ask you to try one medicine to treat your illness before we will cover a different medicine. If the first medicine does not work for you, then we will cover the other drug.
My medicine is not listed on the Healthfirst formulary for my plan or program. What should I do?
As a new or continuing member, you may be taking medicines that are not on our list of covered medicines, or "formulary." Or you may be taking a drug that is on our formulary, but the amount of medicine is limited or at a higher cost.
Talk to your doctor to help you decide what to do. You may be able to switch to an appropriate drug covered by Healthfirst. You may also want to ask for a “formulary exception” to see if we will cover your medicine.
I really need this medicine. How do I ask for an exception to the Healthfirst formulary?
If your medicine is not covered by your Healthfirst plan or program, you can ask us to make one of the following “exceptions” to our coverage rules:
Formulary - You can ask us to cover your medicine, even if it is not on our formulary.
- If we agree to cover a drug that is not on our formulary list, you may not ask us to provide a higher level of coverage for the drug.
- Healthfirst will only make this exception if a different medicine would not be as good at treating your illness. Or if a different drug would cause you to get sick in some way.
- Utilization - If your drug has a quantity limit and you need more, you can ask us to cover the extra amount.
- Tiering – The price of a drug is determined by what “tier” it is on within your formulary. A generic drug may appear on a “preferred tier,” while a brand-name drug may appear on a “non-preferred tier.” If your medicine is listed on a non-preferred tier, it may be more expensive. You can ask us to make your medicine less expensive by covering it like it is on the preferred tier.
Please contact us to ask for a coverage decision if you need a formulary, utilization, or tiering exception.
What do I need to get from my doctor to get an exception?
To get an exception, your doctor will need to give us a “supporting statement” – a letter telling us why you need a special medicine. We usually decide on the exception within 72 hours (3 days) of getting your doctor’s supporting statement. You or your doctor can ask for an expedited (fast) exception if your health could be harmed by waiting for 72 hours. If we agree to an expedited exception, we will answer you within 24 hours (1 day) after we get your doctor’s supporting statement.
In some cases, we will cover up to a 31-day emergency supply of a drug while you are trying to get a formulary exception. This can only happen if you have been a Healthfirst member for longer than 90 days.
I’m a new Healthfirst member. My doctor is changing my prescriptions to drugs covered by Healthfirst. While the change happens, what can I do to get the medicine I need?
In certain cases, we may cover your current medicines during the first 90 days the member is covered by a Healthfirst plan or program.
During your first 90 days as a Healthfirst member, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a pharmacy if:
- You need medicines that are not on our formulary;
- Your ability to get your medicines is limited.
After this 30-day supply, we will not pay for refills of these drugs, even if you have been a member of the plan less than 90 days.
One of my family members is in a long-term care facility and needs a medicine that is not on the Healthfirst formulary. Can he get an exception?
If a Healthfirst member lives in a long-term care facility, we will cover a temporary 31-day supply (unless the prescription is written for fewer days). We will cover more than 1 refill of these drugs for the first 90 days the member is on a Healthfirst plan or program.
When a member moves to a long-term care facility, they may need additional medicines or health supplies. The pharmacy can call to get “early refill edits.” If the member is leaving or moving into a long-term care facility and on Part D (Medicare prescription plan), early refill edits will not be used to limit prescription benefits.
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