health, or ability to regain maximum function, or when you are undergoing a current course of treatment using a nonformulary drug. If the information provided is not sufficient to approve or deny the request, we will notify your prescribing Participating Provider that additional information is required in order to make a determination. This additional information will be due within five calendar days for standard requests or two business days for expedited requests. After we receive the first piece of information (including documents) we requested, we will make a decision and send notification within four calendar days (for standard requests) or two days (for expedited requests), or by the deadline for receiving the information, whichever is sooner. If the exception request is approved through this exception process, then we will cover the drug or supply at the applicable Cost Share shown in the “Benefit Summary.” If the exception request is not approved, we will send you a letter informing you of that decision. You may request a review by an independent review organization. The process is explained in our denial letter and under “External Review” in the “Grievances, Claims, Appeals, and External Review” section. Drug Formulary Exception Process Our drug Formulary guidelines include an exception process that is available when a Participating Provider or any licensed dentist prescribes a drug or supply that our drug Formulary does not list for your condition, if the law requires the item to bear the legend “Rx only.” The exception process is not available for drugs and supplies that the law does not require to bear this legend, or for any drug or supply prescribed by someone other than a Participating Provider or any licensed dentist. A Participating Provider or any licensed dentist may request an exception if they determine that the non-Formulary drug or supply is Medically Necessary. We will make a coverage determination within 72 hours of receipt for standard requests and within 24 hours of receipt for expedited requests. A request may be expedited if you are experiencing a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, or when you are undergoing a current course of treatment using a nonformulary drug. If the information provided is not sufficient to approve or deny the request, we will notify your prescribing Participating Provider that additional information is required in order to make a determination. This additional information will be due within five calendar days for standard requests or two business days for expedited requests. After we receive the first piece of information (including documents) we requested, we will make a decision and send notification within four calendar days (for standard requests) or two days (for expedited requests), or by the deadline for receiving the information, whichever is sooner. We will approve the exception if all of the following requirements are met:  We determine that the drug or supply meets all other coverage requirements except for the fact that our drug Formulary does not list it for your condition.  Medical Group or a designated physician makes the following determinations: • The drug or supply is Medically Necessary because you are allergic to, or intolerant of, or have experienced treatment failure with, any alternative drugs or supplies that our drug Formulary lists for your condition. • Your condition meets any additional requirements that the Regional Formulary and Therapeutics Committee has approved for the drug or supply. For this drug or supply, the pharmacy can provide a copy of the additional criteria upon request. In some cases, there may be a short delay in filling your prescription while your information is being reviewed. EWCLGDED1983ACT0124 61 WAPEBB-CL-ACT