Requesting a medication that is not on your formulary 1

If you need a medication that is not covered on your formulary, you or your prescriber may request a review for coverage. This is called a formulary exception request. There are two levels of review for a medication exception: an internal review by Select Health and, if we uphold a coverage denial, an external review by an independent organization.

Internal medication exception process

1. Your prescriber submits a request. To start an exception request, your prescriber submits a preauthorization (PA) request for the non-formulary medication, along with a statement explaining why it is medically necessary for your condition.
2. We review and decide. We notify you and your prescriber of our decision within the timeframes listed below.
3. If we deny the request, you can appeal. You or your prescriber may request an appeal, and we will review the original decision.
4. We send you a communication of our decision. If we uphold the denial, our communication explains your right to request an external review.

If we uphold a denial of your formulary exception request, you have the right to an external review. You or your prescriber may request that the original exception request and our denial be reviewed by an Independent Review Organization (IRO), a qualified third party not connected to Select Health.

Once we receive your request for external review, we forward it to the IRO. The IRO reviews the case, sends us its decision, and we communicate that decision to you and your prescriber. The IRO's decision is binding.

How to submit a formulary exception request

Internal exception request:

• Your doctor’s office submits a PA request to us. You can also file a PA on your own (not recommended) by visiting selecthealth.org/pa or by using this form: https://selecthealth.rxeob.com/patientdashboard_sh/secure/documents_sh/pa_rxselect/general_exception.pdf.

Internal appeal (if the PA is denied):

• Form: Appeal Form
• Phone: 844-208-9012
• Fax: 801-442-0762
• Email: appeals@imail.org
• Mail: P.O. Box 30192, Salt Lake City, UT 84130-0192

External review:

• Form: External Review Request Form
• Phone: 844-208-9012
• Fax: 801-442-0762
• Mail: P.O. Box 30192, Salt Lake City, UT 84130-0192

Requesting an expedited review (exigent circumstances)

If waiting for a standard decision could seriously harm your health, you can ask for an expedited review.

• Who can request it: You, your authorized representative, or your prescriber.
• How to request it: Call 844-208-9012, and state that you are requesting an expedited review due to exigent circumstances. You may also submit the applicable form by fax and mark the request as expedited (the Appeal Form has an "Ask for an expedited appeal" checkbox).
• What happens next: Select Health decides expedited exception requests within 24 hours. If we uphold a denial, an expedited external review by the IRO is completed within 24 hours of the IRO receiving your request.