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How do I request an exception to the Touchstone Health’s (HMO-
POS) Formulary?
You can ask Touchstone Health (HMO-POS) to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. 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. For example, for certain drugs, Touchstone Health (HMO-POS) limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more. You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. “Also, you may not ask us to provide a higher level of coverage for drugs that are in the specialty tier.” Generally, Touchstone Health (HMO-POS) will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization
restriction exception. When you are requesting a formulary, tiering or utilization restriction exception
you should submit a statement from your physician supporting your request. Generally, we must
make our decision within 72 hours of getting your prescribing physician’s supporting statement. You can
request an expedited (fast) exception if you or your doctor believe that your health could be seriously
harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a
decision no later than 24 hours after we get your prescribing physician’s supporting statement.
Your physician must submit a statement supporting your coverage determination or exception
request. In order to help us make a decision more quickly, you should include supporting medical
information from your doctor when you submit your exception request.
What if I have additional questions?
You can call us at: 1-800-546-5677 (seven days a week, 24 hours a day) if you have any additional questions. If you have a hearing or speech impairment, please call us at TTY 1-866-706-4757. Current as of: July 27, 2012
Atacand, Atacand HCT, Benicar, Benicar HCT, Diovan, Diovan HCT, Exforge, Exforge HCT, Tekamlo, Tekturna, and Tekturna HCT shall be considered medically necessary for members who have had an adequate trial of one month of therapy on losartan, losartan/hctz, lisinopril, quinapril, fosinopril, fosinopril/hctz, moexepril, moexepril/hctz, quinapril/hctz, enalapril, enalapril/hctz, quinapril/hctz, lisinopril/hctz, benazepril, benazepril/hctz, captopril, captopril/hctz, or trandolapril within the previous 180 days as determined by on-line prescription drug claim history. An adequate therapeutic trial will be considered one month of therapy. If criteria is met, the member’s claim for the medication subject to step therapy shall be covered. If on-line prescription claims history is not available, please contact the customer service center at 1-800-546-5677 to request coverage as a medical exception. Avodart and Jalyn shall be considered medically necessary for members who have had an adequate trial of one month of therapy on tamsulosin, doxazosin, finasteride, or terazosin within the previous 180 days as determined by on-line prescription drug claim history. An adequate therapeutic trial will be considered one month of therapy tried. If criteria is met, the member’s claim for the medication subject to step therapy shall be covered. If on-line prescription claims history is not available, please contact the customer service center at 1-800-546-5677 to request coverage as a medical exception. Byetta, Actoplus Met, Duetact, Janumet, and Onglyza shall be considered medically necessary for members who have had an adequate trial of one month of therapy on glyburide, glimepiride, glipizide/metformin, glipizide, glyburide/metformin, or metformin within the previous 180 days as determined by on-line prescription drug claim history. An adequate therapeutic trial will be considered one month of therapy tried. If criteria is met, the member’s claim for the medication subject to step therapy shall be covered. If on-line prescription claims history is not available, please contact the customer service center at 1-800-546-5677 to request coverage as a medical exception. Arthrotec and Celebrex shall be considered medically necessary for members who have had an adequate trial of one month of therapy on two of the following therapies: diclofenac, etodolac, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meclofenamate, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, or tolmetin, within the previous 180 days as determined by on-line prescription drug claim history. An adequate therapeutic trial will be considered one month of therapy tried. If criteria is met, the member’s claim for the medication subject to step therapy shall be covered. If on-line prescription claims history is not available, please contact the customer service center at 1-800- 546-5677 to request coverage as a medical exception. Beconase AQ, Nasonex, and Rhinocort Aqua shall be considered medically necessary for members who have had an adequate trial of one month of therapy on fluticasone or flunisolide within the previous 180 days as determined by on-line prescription drug claim history. An adequate therapeutic trial will be considered one month of therapy tried. If criteria is met, the member’s claim for the medication subject to step therapy shall be covered. If on-line prescription claims history is not available, please contact the customer service center at 1-800-546-5677 to request coverage as a medical exception. Enablex, Oxytrol, and Toviaz shall be considered medically necessary for members who have had an adequate trial of one month of therapy on oxybutynin or oxybutyinin er within the previous 180 days as determined by on-line prescription drug claim history. An adequate therapeutic trial will be considered one month of therapy tried. If criteria is met, the member’s claim for the medication subject to step therapy shall be covered. If on-line prescription claims history is not available, please contact the customer service center at 1-800-546-5677 to request coverage as a medical exception. Current as of: July 27, 2012
Actonel shall be considered medically necessary for members who have had an adequate trial of one month of therapy on alendronate within the previous 180 days as determined by on-line prescription drug claim history. An adequate therapeutic trial will be considered one month of therapy tried. If criteria is met, the member’s claim for the medication subject to step therapy shal be covered. If on-line prescription claims history is not available, please contact the customer service center at 1-800-546-5677 to request Avinza, Kadian, and Oxycontin shall be considered medically necessary for members who have had an adequate trial of one month of therapy on morphine sulfate ER within the previous 180 days as determined by on-line prescription drug claim history. An adequate therapeutic trial will be considered one month of therapy tried. If criteria is met, the member’s claim for the medication subject to step therapy shal be covered. If on-line prescription claims history is not available, please contact the customer service center at 1-800-546-5677 to request coverage as a medical exception. Aciphex and Nexium shall be considered medically necessary for members who have had an adequate trial of one month of therapy on pantoprazole, lansoprazole or omeprazole within the previous 180 days as determined by on-line prescription drug claim history. An adequate therapeutic trial will be considered one month of therapy tried. If criteria is met, the member’s claim for the medication subject to step therapy shall be covered. If on-line prescription claims history is not available, please contact the customer service center at 1-800-546-5677 to request coverage as a medical exception. Lunesta, Rozerem, and Edluar shall be considered medically necessary for members who have had an adequate trial of one month of therapy on zaleplon or zolpidem within the previous 180 days as determined by on-line prescription drug claim history. An adequate therapeutic trial will be considered one month of therapy tried. If criteria is met, the member’s claim for the medication subject to step therapy shal be covered. If on-line prescription claims history is not available, please contact the customer service center at 1-800-546-5677 to request coverage as a medical exception. Vytorin, Lipitor, Lescol, Lescol XL, Crestor, and Zetia shall be considered medically necessary for members who have had an adequate trial of one month of therapy on lovastatin, fluvastatin, pravastatin, or simvastatin within the previous 180 days as determined by on-line prescription drug claim history. An adequate therapeutic trial will be considered one month of therapy tried. If criteria is met, the member’s claim for the medication subject to step therapy shall be covered. If on-line prescription claims history is not available, please contact the customer service center at 1-800-546-5677 to request coverage as a Uloric shall be considered medically necessary for members who have had an adequate trial of one month of therapy on allopurinol, probenecid, or probenecid/colchicine within the previous 180 days as determined by on-line prescription drug claim history. An adequate therapeutic trial will be considered one month of therapy. If criteria is met, the member’s claim for the medication subject to step therapy shal be covered. If on-line prescription claims history is not available, please contact the customer service center at 1-800- 546-5677 to request coverage as a medical exception. Current as of: July 27, 2012
Vectical shall be considered medically necessary for members who have had an adequate trial of one month of therapy on Calcipotriene within the previous 180 days as determined by on-line prescription drug claim history. An adequate therapeutic trial will be considered one month of therapy. If criteria is met, the member’s claim for the medication subject to step therapy shall be covered. If on-line prescription claims history is not available, please contact the customer service center at 1-800-546-5677 to request coverage Elidel and Protopic shall be considered medically necessary for members who have had an adequate trial of one month of therapy on alclometasone, amcinonide, betametasone, clobetasol, desonide, desoximetasone, diflorasone, fluocinolone, fluocinonide, fluticasone, halobetasol, hydrocortisone, mometasone, prednicarbate, or triamcinolone within the previous 180 days as determined by on-line prescription drug claim history. An adequate therapeutic trial will be considered one month of therapy. If criteria is met, the member’s claim for the medication subject to step therapy shal be covered. If on-line prescription claims history is not available, please contact the customer service center at 1-800-546-5677 TOPICAL IMMUNO to request coverage as a medical exception. Trilipix shall be considered medically necessary for members who have had an adequate trial of one month of therapy on fenofibrate within the previous 180 days as determined by on-line prescription drug claim history. An adequate therapeutic trial will be considered one month of therapy. If criteria is met, the member’s claim for the medication subject to step therapy shall be covered. If on-line prescription claims history is not available, please contact the customer service center at 1-800-546-5677 to request coverage Current as of: July 27, 2012

Source: http://touchstoneh.com/downloads/partd/TSH_ST_Criteria_2012.pdf