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Non-formulary exceptions

The prescriber makes the final decision on appropriate therapy for his/her patient. If the established Drug Formulary does not adequately meet the member’s/patient’s clinical needs, a Non-Formulary Drug may be considered for use on an exception basis. Non-formulary drugs are used only if:

  • The member/patient fails to respond to the maximum doses of a formulary drug, as documented in the medical record.
  • There is a high expectation that the member/patient will fail maximum doses of a formulary drug, as documented in the medical record.
  • The member is allergic or intolerant to the formulary drug, as documented in the medical record.
  • There is no other dosage form available on the formulary, as documented in the medical record.