How can I request an exception to my plan's prescription drug formulary to cover a medication that is not listed?

To get an exception to your health plan's drug formulary, your doctor must submit a formal request to the plan explaining why the non-formulary medication is medically necessary for your treatment. The plan must then review this request and make a decision within a specific timeframe. Here are the steps to request a formulary exception: Step 1: Talk to Your Prescribing Doctor Contact the doctor who prescribed the medication. Explain that it is not on your health plan's formulary and that you need their help to request an exception. The request must be initiated by your doctor. Step 2: Your Doctor Must Justify Medical Necessity Your doctor will need to provide a statement to your health plan explaining why the non-formulary drug is medically necessary. Under California law, this means showing that all covered formulary drugs would be ineffective, would cause you adverse side effects, or have already been tried without success. Step 3: Submit the Exception Request Your doctor's office will submit the formal exception request and the statement of medical necessity directly to your health plan. Ask your doctor for a copy of the request for your records. Step 4: Await the Plan's Decision California law requires your health plan to respond quickly. For a standard request, the plan must make a decision within 72 hours. If your doctor states that a delay would pose a serious threat to your health, the plan must respond within 24 hours. Step 5: Appeal a Denial If your health plan denies the request, it must provide a written explanation. You have the right to appeal this decision directly with your health plan. The denial letter will include instructions and deadlines for filing an appeal. Step 6: Request an Independent Medical Review (IMR) If your plan denies your appeal, you can request an IMR from the California Department of Managed Health Care or the Department of Insurance. This is a free review by an independent medical expert. Your health plan is legally required to follow the IMR's decision. Important Considerations: Keep detailed records of all communication with your doctor and your health plan, including dates, names, and what was discussed. The strength of your doctor's statement is the most critical part of the request. Warnings and Limitations: Approval is never guaranteed, even with your doctor's support. This process can be frustrating, so persistence is key. Follow all deadlines for appeals strictly, as missing one can end your right to further review. This is general information and does not constitute legal advice. For complex situations, consult with a qualified California attorney who specializes in health insurance law.