Ask for An Exception

You or your doctor may ask FHCP to make an exception to our Part D coverage rules in a number of situations.

  • You may ask us to cover your drug even if it is not on our formulary. Excluded drugs cannot be covered by a Part D plan unless coverage is through an enhanced plan that covers those excluded drugs.
  • You can ask us to waive coverage restrictions or limits on your Part D drug. For example, for certain Part D drugs, we limit the amount of the drug that we will cover. If your Part D drug has a quantity limit, you may ask us to waive the limit and cover more.
  • You can ask us to provide a higher level of coverage for your Part D drug. If your Part D drug is contained in our non-preferred tier (Tier 2 and/or 4), you may ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier (Tier 1 and/or 3) instead. This would lower the co-insurance/co-payment amount you must pay for your Part D drug. Please note, if we grant your request to cover a Part D drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. You may not ask us to provide a higher level of coverage for Part D drugs that are in the high-cost Tier 6.

Generally, we will only approve your request for an exception if the alternative Part D drugs included on the plan formulary or the Part D drug in the preferred tier would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

Your physician must submit a statement supporting your exception request. In order to help us make a decision more quickly, the supporting medical information from your doctor should be sent to us with the exception request.

If we approve your exception request, our approval is valid for the remainder of the plan year, so long as your doctor continues to prescribe the Part D drug for you and it continues to be safe and effective for treating your condition. If we deny your exception request, you can appeal our decision.

To obtain an aggregate number of Exceptions filed with Florida Health Care Plans, please contact Member Services at 386-615-4022 or 1-877-615-4022. From November 15 through March 1 of each year the hours of operation is 7 days a week, 8 a.m. to 8 p.m. From March 2 through November 14 of each year the hours of operation is Monday through Friday, 8 a.m. to 8 p.m. The hearing impaired may call TTY at 1-877-260-8312.

PROVIDERS - To assist you in submitting a request for an Exception or Prior Authorization on behalf of your patient, please complete FHCP's Medicare Part D Coverage Determination form.To access the document(s) Adobe Reader® must be installed on your computer. If you do not have Adobe Reader ®, you can download it for free by clicking here.

Once this form is completed it will need to be submitted to FHCP's Member Services Department via phone, fax, email or mail.

Phone:
(386) 615-4022 or 1 (877) 615-4022
Fax:
(386) 676-7149
Mail:
Florida Health Care Plans
Attn: Member Services
1340 Ridgewood Avenue
Holly Hill, FL 32117