Drug exception time frames and enrollee responsibilities

Prevea360 Health Plan relies on Navitus Health Solutions, a full-service pharmacy benefit company to administer the exception process.

To seek an exception, submit the Member Exception to Coverage Request form. Complete the required criteria and fax the form to 855-668-8551. To request an expedited review, you must identify in writing on the form that your request should be expedited.

If the drug is denied, you have the right to an external review. If you feel we have denied the non-formulary request incorrectly, you may ask us to submit the case for an external review by an impartial, third-party reviewer known as an Independent Review Organization (IRO). We must follow the IRO's decision.

An IRO review may be requested by a member, member's representative, or prescribing provider by mailing, calling or faxing the request. Learn more at healthcare.gov.

For specifics on the exception process, see the process created and maintained by Navitus.

This information pertains only to our QHP plans