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Provider Manual

Exception process

Last Updated on August 28, 2018

The prescription drug coverage exception process

You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

  • You can ask us to cover a drug even if it is not on our formulary.
  • You can ask us to waive coverage restrictions or limits on a drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If the drug has a quantity limit, you can ask us to waive the limit and cover more.
  • You can ask us to provide a higher level of coverage for a drug. For example, if a drug is usually considered a Tier 4 drug, you can ask for tier relief to cover it as a Tier 3 drug. This would lower the copayment amount paid for the drug.

Please note, if we grant a request to cover a drug that is not on our formulary, tier relief is not available.

Generally, we will only approve a request for an exception if the alternative drugs are included on the plan’s formulary or the lower-tiered drug would not be as effective in treating the condition and/or would cause adverse medical effects.

A decision by Security Health Plan concerning an exception request constitutes a coverage determination; therefore, all of the coverage determination requirements and timeframes described in the coverage determination process section apply.

In order to help us make a decision more quickly, you should include supporting medical information in submitting  the exception request.

If we approve the exception request, our approval is valid for the remainder of the plan year, so long as you continue to prescribe the drug and it continues to be safe and effective for treating the condition. If we deny the exception request, you can appeal our decision.

Providers or their agent(s) may initiate requests for formulary exceptions or authorizations via:

  • Security Health Plan Pharmacy request line at 1-877-873-5611 or 715-221-9604 
  • Security Health Plan Pharmacy fax number at 715-221-9989 
  • Security Health Online (requires login with user name and password)