Drug Exception Timeframes and Member Responsibilities
December 2024Drug Exception Timeframes and Member Responsibilities You can ask our plan to make an exception to our prescription drug coverage rules. There are several types of exceptions 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 pre-determined cost sharing level (tier), and you would not be able to ask us to provide the drug at a lower costsharing level.
- You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan 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, our plan will only approve your request for an exception if the alternative drug is included on the plan’s formulary, the drug with lower cost share or additional utilization restrictions would not be as effective in treating your condition and/or the alternative drug would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering (cost sharing level) or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or doctor 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.
Prime Therapeutics is the Pharmacy Benefit Manager (PBM) for Alliant. You can make a Formulary Exception Request online by using our online form or by calling Prime Member Services at (844) 451-8288 to initiate the exception request. Pharmacy Coverage Exception Request information can be found at www.myprime.com/v/ALLIANT/COMMERCIAL/en/coverage-exception-form.html
If you disagree with our decision you have the right to request an external review by an Independent Review Organization (IRO). Alliant uses the federal process for Georgia-based plans and contracts with multiple IROs for Tennessee-based plans. There is no charge to you for the external review to be done.
For Georgia-based plans (Individual and Group):
- You, your representative, or prescribing doctor can submit a request for external review online at www.externalappeal.cms.gov, by calling (888) 866-6205 to ask for an external review request form, or by sending the request via email to ferp@maximus.com. To request an external review by fax or mail:
MAXIMUS Federal Services 3750 Monroe Avenue, Suite 705
Pittsford, NY 14534
Fax: (888) 866-6190
For Tennessee-based plans (Individual and Group):
- You, your representative, or prescribing doctor can submit a request for external review by calling (800) 865-5922 to ask for an external review request form. To request an external review by fax or mail:
Alliant Health Plans
Appeals Department
PO BOX 1247
Dalton, GA 30722
Fax: (866) 634-8917
