Samaritan Select

Medication exception

You can ask us to make a medication exception to our coverage rules. This includes exceptions for:

• Covering your drug even if it is not on the formulary;
• Waiving coverage restrictions or limits on your drug;
• Providing a higher level of coverage 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 that drug.

Generally, we will only approve your request for an exception if the alternative drugs included on the Plan’s formulary or the lower-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

In order to help us make a decision more quickly, you should include supporting medical information from your doctor when you submit your medication exception request (click here for Medication Exception form). If we approve your medication exception request, the approval time will be made on a case-by-case basis. We will continue to pay for the drug for the duration of the approval time, so long as your doctor continues to prescribe the drug for you and it continues to be safe and effective for treating your condition. If we deny your medication exception request, you can appeal our decision. See your plan document for instructions on how to file an appeal.