Formulary Exception: Non-Formulary Drugs

If your drug is not included on the CCHP SelectCare (HMO) Formulary, you should first contact Member Services and ask if your drug is covered. If you learn that CCHP SelectCare (HMO) does not cover your drug, you have two options:

1. You can ask Member Services for a list of similar drugs that are covered by CCHP SelectCare (HMO) . When you receive the list, show it to your physician or other prescriber and ask him or her to prescribe you one of the drugs from that list.
2. You can ask us to make an exception and cover your drug. Your physician or other prescriber must submit a letter of medical necessity for you. Generally, CCHP SelectCare (HMO) will only approve your request for a non-formulary drug exception if the alternative drugs included on the CCHP SelectCare (HMO) formulary, would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

Non-Formulary Drug Restrictions:

Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to cover it at a lower cost-sharing level.

Also, due to a change in Medicare, most Medicare Drug Plans no longer cover erectile dysfunction (ED) drugs like Viagra, Cilais, Levitra, and Caverject.

Generally, we must make our decision within 72 hours of getting you or your physician's or other prescribers' request for standard coverage determinations or 24 hours of getting you or your prescribing physician's request for an expedited coverage determination.

Members who would like to request an exception or check on the status of an exception request submitted by their physician or other prescriber should contact our Member Services Department 8:00 a.m. to 8:00 p.m., seven days a week:

Click here to download the Enrollee's Coverage Determination Request Form. Mail or fax the completed form to:

CCHP SelectCare (HMO)
Prior Authorization Department
200 Stevens Drive
Philadelphia, PA 19113
Fax Standard: 1-866-426-7616
Fax Expedited: 1-866-785-3625

Click here for the Appointment of Representative Form and for more information on how to appoint a representative.

Physicians and other prescribers who would like to submit an exception request may either contact our Provider Help Desk at 1-866-205-0749, or use our physician's coverage determination form available below. Please answer all questions on the form and fax to the phone number listed on the form.

Click here for the Physician's Coverage Determination Request Form. Fax or mail the completed form to:

CCHP SelectCare (HMO)
Prior Authorization Department
200 Stevens Drive
Philadelphia, PA 19113
Fax Standard: 1-866-426-7616
Fax Expedited: 1-866-785-3625

What can I do if my Coverage Determination is denied?

If CCHP SelectCare (HMO) denies your coverage determination you have the right to request a redetermination appeal. Please see our section on Appeals and Grievances for information about your appeal rights, or contact our Member Services Department 8:00 a.m. - 8:00 p.m., seven days a week.

Click here for more information on Appeals & Grievances.