Formulary Exception: Quantity Limits

For certain drugs, CCHP SelectCare (HMO) may limit the number of doses that you can receive during a set number of days. For example, CCHP SelectCare (HMO) provides nine tablets per prescription for Imitrex. This may be in addition to a standard one month or three month supply. You can ask us to waive the limit and cover more. Your physician or other prescriber must submit a statement of medical necessity that states why the quantity limit would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You can ask CCHP SelectCare (HMO) to make an exception to our coverage rules. If you are requesting an exception to the formulary rules (on prior authorization or other utilization management tool) you should submit a statement from your physician or other prescriber supporting your request.

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 lik 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. - 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.