Medicare Part D Prescription Drug Exceptions Process

What if my drug is not on the Formulary?

If your drug is not included in the SummaCare Medicare Part D formulary (list of covered drugs), you can ask SummaCare to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a predetermined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, SummaCare limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, SummaCare will only approve your request for an exception if the alternative drugs included on the plan’s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?

As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover at least a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After we cover your temporary supply as described above, we will not pay for these drugs, even if you have been a member of the plan less than 90 days, unless you have been granted an exception. 

If you are a resident of a long-term care facility, we will cover at least a 31-day supply.  If your prescription is written for fewer days, we will allow multiple fills to provide up to at least a 31-day supply of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.) If you need a prescription drug that is not on our Formulary (or if your ability to get your drugs is limited), and you are past the first 90 days of your SummaCare Medicare membership, we will cover at least a 31-day emergency supply of that prescription drug (unless you have a prescription written for fewer days) while you pursue a Formulary Exception.

If you are a current member of SummaCare Medicare and experience a change in your level of care from one treatment setting to another, we will cover a transition supply of each prescription drug that is either not on our Formulary or covered on our Formulary but also subject to certain requirements or limits on coverage. At least a one-time temporary fill of at least a month’s supply of medication will be provided to current long-term care enrollees who enter into a facility from another care setting.

Medicare Part D Coverage Determination Request

MedImpact Healthcare Systems, Inc.
10181 Scripps Gateway Court
San Diego, CA 92131
Fax: 858.790.7100

You can also submit an electronic coverage determination request. This will enable you to complete the form online and submit directly to MedImpact upon completion.