Common use of Exception Process Clause in Contracts

Exception Process. If a Prescription Drug, including contraceptives, is not on Our Formulary, You, Your designee or Your prescribing Health Care Professional may request a Formulary exception for a clinically- appropriate Prescription Drug in writing, electronically or telephonically. The request should include a statement from Your prescribing Health Care Professional that all Formulary drugs will be or have been ineffective, would not be as effective as the non-Formulary drug, or would have adverse effects. If coverage is approved, the costs will count toward the Out-of-Pocket Maximum. If coverage is denied under Our standard or expedited Formulary exception process, You are entitled to an external appeal as outlined in the Complaints, Appeals and External Review section of this Policy. Visit Our website at ▇▇▇.▇▇▇▇▇▇▇.▇▇▇ or call ▇-▇▇▇-▇▇▇▇▇-▇▇ to find out more about this process. For contraceptives only, We will defer to Your Provider’s recommendation of Medical Necessity and will provide the contraceptive service or FDA approved item without cost sharing upon request. Coverage and benefits for Covered Prescription Drugs and Supplies and Covered OTC Drugs are subject to the following limitations in addition to all other provisions and exclusions in this Contract.