Exceptions and Prior Authorization
What is an Exception?
You can ask Community CCRxSM 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 your drug even if it is not on our formulary.
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Community CCRx 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 more.
You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our Non-Preferred Brand tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the Preferred Brand tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty tier.
Generally, Community CCRx will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the Preferred-Brand drug 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 are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe 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 your prescribing physician’s supporting statement.
What is a Prior Authorization?
Community CCRx requires you to get prior authorization for certain drugs. This means that you will need to get approval from Community CCRx before you fill your prescription. If you do not get approval, Community CCRx may not cover the drug.
Click to print Exception and Prior Authorization forms.