Asking for an exception

We expect that the drugs on the Approved Drug List for your plan will meet all your prescription drug needs. However, if your doctor prescribes a drug that's not covered, you may request an exception. 

Here's the process for asking for an exception:

1. Your doctor will fill out a drug authorization request form that explains why you need the non-formulary drug and fax in to or send it electronically through their provider portal. These medications are initially reviewed for medical necessity exception by Priority Health through the Prior Authorization review process. To request an expedited review for exigent circumstance, have your provider mark ‘Urgent’ (request for expedited review) option on the request form. Unless there are medical reasons for us to respond more quickly, we’ll generally make a decision within 72 hours of your request for a coverage determination or exception.
2. Priority Health will let you and your doctor know whether or not we approve the drug for you. If approved, the drug is covered at the highest applicable cost-sharing level after deductible, depending upon your pharmacy plan design.
3. If you feel we have denied the non-formulary request incorrectly, you may request Priority Health change the decision by filing an appeal. To file an appeal with Priority Health please call 616.464.8830.
4. If you are not satisfied with the outcome of the appeal, you may submit the case for external review by an impartial, third-party reviewer known as an independent review organization (IRO). We must follow the IRO's decision. An IRO review may be requested by you, your representative, or your prescribing provider by calling 877.999.6442. For standard exception review of medical requests where the request was denied, the timeframe for review is 72 hours from when we receive the request. For expedited exception review requests where the request was denied, the timeframe for review is 24 hours from when we receive the request.