Short answer: Ask your plan for a formulary exception or prior authorization with your doctor’s supporting statement. If the plan still denies it, you have the right to an internal appeal and then an independent external review.
If a drug is not on your plan’s formulary, or requires prior authorization or step therapy, your prescriber can request a coverage determination or formulary exception. This usually means the doctor submits a statement explaining why the specific drug is medically necessary, for example, that covered alternatives were ineffective or caused harmful side effects.
If the request is denied, federal law gives you appeal rights. You can file an internal appeal asking the plan to reconsider, and if it upholds the denial, you can request an external review by an independent third party whose decision the plan must follow. Expedited (fast) reviews are available when waiting could seriously jeopardize your health.
Keep records of every request and denial letter, ask the plan for the specific reason and the deadline to appeal, and enlist your prescriber’s office, which handles these requests regularly. For urgent needs, ask about expedited review and any short-term supply the pharmacy can provide while the appeal is pending.