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Pharmacy Exceptions & Appeals

Filing an Exception

If a drug isn't covered the way you want it to be, you can ask us to make an exception. An exception is a type of coverage determination. If we turn down your request, you can appeal our decision.

There are different types of exceptions:

  • You can ask us to cover your drug even if it is not on our formulary.
  • You can ask us to waive coverage restrictions or limits on your drug. If your drug has a quantity limit, you can ask us to waive the limit and cover a larger quantity.
  • Generally, we will only approve your request if other drugs on your plan’s formulary or if a drug’s usage restrictions would not be effective in treating your condition.

There are two ways you, your doctor, or your appointed representative may file a request for an exception:

Call us at 866-270-3877 (TTY 711).

As a first step, you should ask us for an initial coverage decision for a formulary or drug restriction exception.


 

Mail or fax

Complete and mail or fax the Coverage Determination Request Form and a doctor’s supporting request to:

Navitus Health Solutions
P.O. Box 1039
Appleton, WI 54912-1039
Fax: 1-855-668-8552

One Care Coverage Determination Request Form (pdf)
SCO Coverage Determiniation Request form (pdf)

Your doctor must submit a statement supporting your request that explains why the requested drug is medically necessary. If the exception involves a prior authorization or other limit, the doctor’s statement must explain why the prior authorization or limit would not be effective for you.

  • Time Period for Our Decision
    • Generally, we must make our decision within 72 hours of getting your doctor’s statement. You can request a faster (expedited) decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours. If your request is granted, we must give you a decision no later than 24 hours after we get your doctor’s statement.

Filing an Appeal

You have the right to file an appeal if you disagree with a coverage decision we make. You would file an appeal if you want us to change a decision we've made about what prescription drugs are covered for you.

There are three ways you, your doctor, or your appointed representative may file a an appeal:

Call us at 866-610-2273 (TTY 711)


 

Use your MassHealth appeal rights.

You may request a fair hearing from MassHealth no later than 30 calendar days from the date you received your written denial notice from Commonwealth Care Alliance. The request must contain:
  • Your name
  • Your address and phone number
  • Your MassHealth ID number or Social Security number
  • Your reason for appeal If you would like your hearing to be scheduled as soon as possible
  • If you need an interpreter to be provided

If you would like to name a representative to appeal on your behalf, the request must be signed and sent via mail or fax to:

Executive Office of Health and Human Services
Board of Hearings
100 Hancock Street, 6th Floor
Quincy, MA 02171
Fax: (617) 847-1204

Please keep one copy of the fair hearing request for your information. If you do not agree with the fair hearing decision, you will have further appeal rights under MassHealth. You will be notified of those appeal rights if this happens.

 
 
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