Formulary Exception: Non Formulary Drugs

If your drug is not included on the SelectCare Formulary, you should first contact Provider Help Desk and ask if your drug is covered. If you learn that SelectCare does not cover your drug, you have two options:

1. You can review the SelectCare Drug Formulary and prescribe a similar drug that is covered by SelectCare.
2. You can ask SelectCare to make an exception and cover the drug. Generally, SelectCare will only approve your request for a non-formulary drug exception if based on your statement of medical necessity, the alternative drugs included on the SelectCare formulary 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.

Non-Formulary Drug Restrictions:

Please note, if we grant your request to cover a drug that is not on our formulary, the member 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.

Providers 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:

SelectCare
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 SelectCare denies the coverage determination the member or their representative has the right to request a redetermination appeal. Physicians have the right to request an expedited 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.