Formulary Exception: Quantity Limits

For certain drugs, CCHP SelectCare (HMO) may limit the number of doses that a member can receive during a set number of days. For example, CCHP SelectCare (HMO) provides 9 tablets per 30 day period 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 must submit a statement of medical necessity on the member's behalf that states why the quantity limit would not be as effective in treating the member's condition and/or would cause the member to have adverse medical effects.

We will give you and the member a decision within 72 hours of getting your statement of medical necessity for a standard exception request or 24 hours of getting your statement of medical necessity for an expedited exception request.

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 be done if a Coverage Determination is denied?
If CCHP SelectCare (HMO) denies the coverage determination the member or their representative has the right to request a redetermination appeal. Physicians and other prescribers, upon providing notice to the enrollee, have the right to request a redetermination appeal on a member's behalf. Please see our section on Appeals and Grievances for information about member 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.