If a drug is not on the formulary, what may be required to obtain coverage?

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Study for the Wellcare ACT Mastery – Broker and Employee Exam. Prepare with our comprehensive materials including flashcards and multiple choice questions, with detailed hints and explanations. Achieve excellent results in your exam!

Multiple Choice

If a drug is not on the formulary, what may be required to obtain coverage?

Explanation:
If a drug isn’t on the formulary, it isn’t covered automatically. In that case, coverage usually requires a non-formulary exception, which often involves obtaining prior authorization. The prescriber must show medical necessity and discuss alternatives, and the insurer will review before approving any coverage. Some plans also include exclusions, meaning the drug may be unavailable unless an exception is granted. This process helps ensure the medication is medically necessary and cost-effective for the member.

If a drug isn’t on the formulary, it isn’t covered automatically. In that case, coverage usually requires a non-formulary exception, which often involves obtaining prior authorization. The prescriber must show medical necessity and discuss alternatives, and the insurer will review before approving any coverage. Some plans also include exclusions, meaning the drug may be unavailable unless an exception is granted. This process helps ensure the medication is medically necessary and cost-effective for the member.

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