Exception
An exception request is a type of coverage determination.
An enrollee, an enrollee’s prescriber, or an enrollee’s representative may request a tiering exception or a formulary exception.
- A tiering exception should be requested to obtain a non-preferred drug at the cost-sharing terms applicable to drugs in the preferred tier.
- A formulary exception should be requested to obtain a Part D drug that is not included on a plan sponsor’s formulary.
For benefit request that involve exceptions, the adjudication timeframes do not begin until the enrollee’s prescriber submits his or her supporting statement. Once we receive a prescriber’s supporting statement, we must provide a decision notice within 24 hours (for expedited requests) or 72 hours (for standard requests).
If the coverage determination is unfavorable, the decision will contain the information needed to file a request for redetermination.
How to file an Exception
You may file a request for an exception by sending us your request in writing. A statement from your doctor or other prescriber indicating the medical reasons for the drug exception you are requesting, must be included.
Your doctor or prescribing physician may also file an exception on your behalf by completing the Medicare Part D Prescription Coverage Determination Request form below (the following link which will redirect you to the CMS website):
https://www.cms.gov/MedPrescriptDrugApplGriev/04_Exceptions.asp
All exception requests can be filed:
Phone: 1-888-767-7717 (TTY users 1-877-672-4242)
Fax: 787-625-8544
Mail: First+Plus
P.O. Box 195080
San Juan, PR 00919-5080
For more information on exceptions please refer to the Evidence of Coverage Chapter 9 “What to do you if you have a problem or complaint (Coverage decisions, Appeals and Complaints)” or call our Customer Service Department at 1-888-767-7717 Monday thru Friday from 8:00 am to 8:00 pm. TTY /TDD users should call 1-877-672-4242.