Is the prescription medicine...

  • identified in the formulary as an exception drug status benefit
  • is it a more expensive version of a listed medicine, or
  • is it not listed on the formulary?

If yes, your prescriber is required to indicate that the medicine is being used for purposes that correspond with the specific criteria set out in the formulary for that specific medication or your prescriber will be required to submit a prior authorization request for you to request that the medication be covered.

If the request is approved, then the medicine would be covered for you in the same way as a regular formulary benefit is managed.

If the request is denied, then it would not be covered by the plan and any payments you make for this medication would not count as part of your cost-sharing responsibilities.

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