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Non-formulary exception process

Non-formulary exception process
Documenting medical necessity

Non-formulary exception process

The non-formulary exception process provides physicians and members with access to non-formulary drugs and facilitates prescription drug coverage of medically necessary, non-formulary drugs as determined by the prescribing practitioner.

Patients can also have a non-formulary drug without invoking the exception process anytime by paying full price for the drug if the prescribing provider deems the non-formulary drug not medically necessary, but agrees to prescribe the drug due to patient demand.

The prescribing practitioner makes the final decision regarding what drug is appropriate for the member.  Non-formulary drugs should be used only if the patient fails to respond to formulary drug therapy, has an adverse reaction to formulary drug, or has other special circumstances requiring the use of a non-formulary drug.

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Documenting medical necessity

If the appropriate drug is not on the formulary and is deemed medically necessary by the prescribing practitioner, the practitioner should document the reason for the medical necessity in the patient’s medical record and on the pharmacy prescription. This documentation is transferred with the prescription to the Kaiser Permanente pharmacy.

If the member is using a network pharmacy, complete the Medication Request Form(MRF)* and fax directly to the Kaiser Permanente Pharmacy Formulary Management Team at 1-866-331-2104.

If a network practitioner writes a prescription for a non-formulary drug without the appropriate exception reason documented, they may expect a telephone call or faxed medication request form (MRF) to obtain a formulary exception reason, or formulary alternative. This allows Kaiser Permanente to track the use of non-formulary agents and decide whether they should be re-evaluated for formulary inclusion.

Reasons why a physician may grant an exception include:

  • allergy/adverse reaction of the member to formulary product
  • treatment failure with a formulary drug
  • meets criteria/guidelines for appropriate use:
    • The choices available in the drug formulary are not suited for the present patient care need and the drug selected is required for patient safety.
    • The use of a formulary drug product may provoke an underlying medical condition, which would be detrimental to patient care 

Once the physician provides any of the above reasons, the prescription will be treated as a non-formulary exception and will be covered.  The appropriate co-payment will then be due from the member.

If the physician determines the non-formulary prescription is not medically necessary, the physician should discuss the formulary alternative available with the member. If the member insists on the non-formulary product but an appropriate formulary alternative is available, the physician may prescribe the non-formulary drug. In this case:

  • The physician will document the non-formulary prescription a patient request/demand.
  • The drug will not be covered under the pharmacy benefit.
  • The patient will pay full price for the drug.

If the physician prescribes a non-formulary prescription drug for a patient without indicating a non-formulary exception reason, and the member attempts to fill the prescription at a network pharmacy, the member may

  • Get the non-formulary medication filled and pay the retail price charged by the pharmacy for the drug, or
  • Ask the pharmacist to request a formulary alternative or a non-formulary exception if appropriate, or
  • Contact Kaiser Permanente Member Services at 1-877-218-7750 and request a non-formulary exception review.
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