Drug exception time frames and enrollee responsibilities

Sometimes you might need access to pharmacy benefit drugs that aren't listed on the plan's formulary (drug list). These medications are initially reviewed by the formulary exception review process administered by our full-service pharmacy benefit company, Navitus Health Solutions.  The member or provider can submit the request to us by faxing the Member Exception to Coverage Request form to 855-668-8551. 

To request an expedited review , you must identify in writing on the form that your request should be expedited. 

For additional details please see the process created and maintained by Navitus Health Solutions.  

If the pharmacy benefit 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 form.
See the state fact sheet on IRO
View certified Wisconsin Independent Review Organizations

Submit your request for an independent review to: 

PO Box 56099
Madison, WI 53705
Fax: 608-252-0812

For standard exception review of medical requests where the request was denied, the timeframe for review is 72 hours from when we receive the request. For expedited exception review requests where the request was denied, the timeframe for review is 24 hours from when we receive the request. 

This information pertains only to our QHP plans