If you’re enrolled in a state-regulated health plan, you, or your medical provider, can request an exception to get a prescription drug covered. Under state law (RCW 48.43. 420) (leg.wa.gov)), this process overrides certain policies health plans may use to limit drug coverage, such as prior authorization, step therapy or “fail first” protocols.
The process to ask your health plan to cover a prescription
The process allows you to ask your health insurer to cover a non-preferred prescription drug or a drug your provider prescribed as “off-label.”
Once you or your provider make a request to your insurer:
- Your insurer must respond within three days unless they need more information from your provider.
- If the request is urgent, your insurer must respond within one day.
The request is automatically approved if you or your provider do not hear back within either time period.
If you’re stable on your medication, your insurer must allow you to remain on that drug while you wait for a decision on your exception request.
Your insurer can require you to try a generic version instead of a brand name. For biological drugs, such as those used to treat autoimmune disorders and cancer, your insurer can require you to substitute with another biological drug.
Your insurer can also deny an exception request for a drug the FDA removed from the market due to safety concerns.
Information you’ll need to get a drug covered
Your health insurer must grant an exception if you or your provider submits information showing:
- You can’t tolerate the covered drug, it causes adverse reactions or it’s harmful to you.
- You tried the covered drug (or another comparable prescription drug) and stopped taking it because it was not effective.
- You require a higher dosage than the health insurer’s formulary allows.
If the drug covered by your health insurer’s formulary is not in your best interest, your insurer can require you or your provider to submit documentation explaining why the formulary drug will impact your care, other conditions or your ability to perform daily activities.
Next steps when coverage is approved
If an exception request is approved and the drug is covered, your insurer must tell you the cost-sharing amount. Health insurers cannot have a special tier or cost-sharing amount that applies only to drugs approved for coverage under this exception process.
Your insurer must approve refills for this drug in these situations:
- You continue to have a valid prescription for the drug, and the drug continues to be FDA-approved for treating your disease or medical condition.
- The drug was prescribed as part of your participation in a clinical trial.
However, your insurer may require you to submit a new exception request for an “off-label” drug prescription when the prescription renewal cycle ends.
What to do if coverage is denied
You or your provider can appeal a denial directly with your health insurer. If your health insurer denies your appeal, you can request a review by an independent review organization (RCW 48.43.535) (leg.wa.gov).
If you win your appeal, your insurer must retroactively cover the nonformulary drug and continue coverage for the duration of the prescription.