We are committed to providing appropriate, high-quality, and cost-effective drug therapy to all Ambetter Healthmembers. Use our Preferred Drug List to find more information on the drugs that Ambetter Healthcovers.
Prescription Drug Exception Request
The member, the member’s designee or the member’s prescribing physician may request an exception to Our Prescription Drug requirements when:
- The drug is not covered based on our formulary.
- We are discontinuing coverage of the drug.
- The drug, as requested, does not conform to the limitations and procedures under Our drug utilization management program such as step therapy, dosage limitations or therapeutic substitutions.
To request this exception the provider can utilize the regular PA request processes and forms available in our website. The provider should make sure to submit any information on previous approval of the drug for your patient or/and reason for requesting the exemption. A Medical Director, pharmacist, or other health care professionals who have appropriate clinical expertise in your patient’s condition will make a determination according to accepted medical practice. We will notify the member and the member’s prescribing physician of our decision within fifteen (15) calendar days or sooner, depending on the request.
If we do not approve the request, the member and the prescribing physician will receive detailed information about why the decision was made, as well as the process and time frame you should follow for submitting appeals.
