Exceptions to the Formulary

For certain prescription drugs, special rules restrict how and when the plan covers them. If there is a restriction for your drug, it usually means that you or your provider will have to take extra steps in order for us to cover the drug. If you want us to waive the restriction for you, you will need to use the coverage decision process and ask us to make an exception. An exception is a type of coverage determination that, if approved, allows you to get a drug that is not on the formulary (a formulary exception).

You can ask us to cover a non-formulary drug or to waive coverage restrictions or limits on a drug. For example, for certain drugs, Passport Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. To view our formulary (or drug list), click here.

You should contact us to ask us for an initial coverage decision for a formulary exception or for a coverage restriction exception. You, your representative, or you doctor (or other prescriber) can do this. A request can be submitted by phone, fax, or mail.

When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician 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 doctor 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 doctor or other prescriber.

You can read more about formulary exceptions in Chapter 9 of our Evidence of Coverage.

 

Requesting an Exception (Members)

Coverage Determination Request Form (Drug Request)

By Mail or Fax

  • Download and print the Coverage Determination Request Form (PDF), or call Member Services at 1-844-859-6152, TTY/TDD 711, and request that the form be mailed to you. Calls to this number are free. Hours of operation are from February 15 to September 30, Monday – Friday, 8 a.m. to 8 p.m. (EST) and from October 1 to February 14, 7 days a week, 8 a.m. to 8 p.m. (EST).
  • Complete the entire form and submit either by fax or mail. The fax number and mailing address are listed at the top of the form.
  • Your physician must submit a statement that none of the drugs used to treat your condition on Passport Advantage’s formulary would be as effective, and/or that all of the formulary drugs have caused you adverse effects.
  • To check the status of your exception request, please contact Member Services 1-844-859-6152, TTY/TDD 711; available from February 15 to September 30, Monday – Friday, 8 a.m. to 8 p.m. (EST) and from October 1 to February 14, 7 days a week, 8 a.m. to 8 p.m. (EST)

Fax Number:
1-855-869-7043

Mail:

Passport Advantage Pharmacy Services
950 N. Meridian Street, Suite 600
Indianapolis, IN 46204

Phone:
1-844-859-6152, TTY/TDD 711; available from February 15 to September 30, Monday – Friday, 8 a.m. to 8 p.m. (EST) and from October 1 to February 14, 7 days a week, 8 a.m. to 8 p.m. (EST)

For coverage requests, after an initial denial, you will need to use this form: Request for Redetermination Form

 

Requesting an Exception (Physicians) 

By Mail or Fax

  • Download and print the Coverage Determination Request Form (PDF) or provide a statement that none of the drugs used to treat your patient’s condition on Passport Advantage’s formulary would be as effective, and/or that all of the formulary drugs have caused adverse effects for your patient.
  • Complete the entire form and submit either by fax or mail. The fax number and mailing address are listed at the top of the form.
  • To check the status of your exception request, please contact Passport Advantage Pharmacy Services Customer Care at 1-844-859-6152.

Fax Number:
1-855-869-7043

Mail:
Passport Advantage Pharmacy Services
950 N. Meridian Street Suite 600
Indianapolis, IN 46204

 

How to Request an Appeal/Redetermination

Request for Redetermination of Medicare Prescription Drug Denial Form

You can generally “appeal” our decision not to cover a drug, vaccine, or other Part D benefit. You may also appeal our decision not to reimburse you for a Part D drug that you paid for or if you think we should have reimbursed you more than you received or if you are asked to pay a different cost-sharing amount than you think you are required to pay for a prescription. Finally, if we deny an exception request or you received an adverse coverage determination, you can appeal.

You need to file your appeal within 60 calendar days from the date included on the specific notification such as the notice of coverage determination. We can give you more time if you have a good reason for missing the deadline.

To file a standard appeal, you, your designated representative, or your prescribing physician can complete the Request for Redetermination Form and submit by fax, mail, or in person. You may also call Passport Advantage Member Services toll-free at 1-844-859-6152, available from February 15 to September 30, Monday – Friday, 8 a.m. to 8 p.m. (EST) and from October 1 to February 14, 7 days a week, 8 a.m. to 8 p.m. (EST). TTY/TDD users call 711. You can send the form or another signed request to:

Mail:
Passport Advantage Pharmacy Services
950 N. Meridian Street, Suite 600
Indianapolis, IN 46204

Fax:
1-855-869-7043

When our plan is reviewing your appeal, we take another careful look at all of the information about your coverage request. We check to see if we were being fair and following all the rules when we said no to your request. We may contact you or your doctor or other prescriber to get more information. After we get your appeal, we have up to 7 calendar days to give you a decision, but will make it sooner if your health condition requires us to. If we do not give you our decision within 7 calendar days, your request will automatically go to the second level of appeal, where an independent organization will review your case.

“Fast” or “Expedited” Appeal

You, your doctor, or your appointed representative may ask us to give a fast appeal (rather than a standard appeal), which is a 72-hour review, by calling Passport Advantage Member Services toll-free at 1-844-859-6152, available from February 15 to September 30, Monday – Friday, 8 a.m. to 8 p.m. (EST) and from October 1 to February 14, 7 days a week, 8 a.m. to 8 p.m. (EST). TTY/TDD users call 711

You may also fax it to us at 502-212-6910 during or outside our regular business hours. Be sure to ask for a “fast,” “expedited,” or “72-hour” review. Remember, that if your prescribing doctor provides a written or oral supporting statement, explaining that you need the fast appeal process, we will automatically treat you as eligible for a fast appeal.

Please see your Evidence of Coverage for more detailed information concerning the grievance and appeal process.

Part D Grievances

Medicare indicates that a grievance is any complaint, other than one that involves a request for an initial determination or appeal. You would file a “grievance” for such issues as the behavior of your pharmacist or excessive wait times at the pharmacy. If you wish to file a grievance with Passport Advantage, you or your designated representative may call Passport Advantage Member Services toll-free at 1-844-859-6152, available from February 15 to September 30, Monday – Friday, 8 a.m. to 8 p.m. (EST) and from October 1 to February 14, 7 days a week, 8 a.m. to 8 p.m. (EST). TTY/TDD users call 711. You may also submit a grievance in written form.

As an enrollee of Passport Advantage, if your complaint is received by telephone, we will address and resolve your complaint by telephone, especially if your complaint involves a possible misunderstanding or misinformation. If you request a written response, or if your concern is regarding a Quality of Care issue, we will respond in writing to you. The grievance must be submitted within 60 days of the event or incident. We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension or if we justify a need for additional information and the delay is in your best interest.

If you choose to submit your grievance in writing, please send it to:

Mail to:
Passport Advantage Pharmacy Services
950 N. Meridian Street, Suite 600
Indianapolis, IN 46204

Fax:
1-855-869-7043

 

 

 

Last Modified: November 16, 2017