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Prescriptions & Part D

Prescriptions & Part D

Coverage Decisions & Exceptions

We will usually cover your prescription drugs if they appear on the Drug List. See the section of our website about the Drug List for more information. For certain prescription drugs, special rules limit how and when the plan covers them. In general, our rules encourage you to get a drug that works for your medical condition and is safe. We also need to comply with Medicare’s rules and regulations for drug coverage and cost sharing.

If there is a special rule for your drug, it usually means that you or your provider will have to take extra steps for us to cover the drug. For example, your provider may have to tell us why you're using the drug or provide results of blood tests first. If you or your provider thinks our rule should not apply to your situation, you should ask us to make an exception. This is called a formulary exception, and it is a type of coverage decision. To ask for an exception, see the section below on “How to ask for a coverage decision.”

Once you or your provider have completed the extra steps, we will make a decision about covering the drug, also called a drug coverage determination. We may or may not agree to let you use the drug without taking the extra steps.

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