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How to Request a Formulary Exception
 There are Two Ways to Request a Formulary Exception
 | Option 1 - Your doctor can contact us by doing the following:
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Printing and completing the Medicare Part D Medication Request Form, and fax the completed form to (650) 616-2190.
Submitting a statement supporting this request. It must indicate that the requested drug is medically necessary for treating your condition because none of the drugs we cover for treating your condition would be as effective as the requested drug or would have adverse effects for you. If the exception involves a prior authorization, quantity limit, or other limit we have placed on a drug you are taking, the doctor’s statement must indicate that the prior authorization or limit would not be as effective for treating your condition or would have adverse effects for you.
| | Option 2 - You can contact us directly. But we still need to get a supporting statement from your doctor.
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Contact the CareAdvantage Unit
Phone: (650) 616-2174 Fax: (650) 616-2190
TTY: 1-800-735-2929 or dial 711
Monday through Sunday, 8 a.m. to 8 p.m.
Our call center hours are Monday through Sunday, 8 a.m. to 8 p.m. Our office hours are Monday through Friday, 8:00 a.m. to 6:00 p.m. We are located at 701 Gateway Blvd. Suite 400, South San Francisco, CA 94080.
For either option you or your doctor needs to ask for a standard decision (72 hours) or an expedited (fast) decision (24 hours).
If you, or your prescribing doctor, believe that waiting for a standard decision could seriously harm your life or health, you can ask for an expedited decision. If your doctor asks for a fast decision for you, he/she can either calls HPSM or fax in a written statement. HPSM will make a decision in 24 hours if your doctor states that he or she agrees that waiting for 72 hours could seriously harm your life or health. If you do not obtain your doctor’s support, HPSM will decide if your health condition requires a fast decision.
HPSM will notify you of our decision on your formulary exception
After we receive your doctor’s statement, we will notify you of our decision no later than 24 or 72 hours, depending on whether your doctor asks for an expedited (fast) decision or a standard decision (72 hours).
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