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Medicare Assured® Formulary Exceptions

You can ask Gateway HealthSM Medicare Assured® to make an exception to our coverage rules.  To contact us please call 1-800-685-5209 (TTY: 711), 8:00am-8:00pm, 7 days per week.

You can also make a request by secure email.  Click here for instructions on how to login and set up an account to submit a request by email.  You may want to print the instruction page.

Click here to request by email.


Please submit the following information to ensure that your request is processed appropriately:

  • Member Name
  • Member ID Number
  • Member DOB
  • Prescriber Name
  • Prescriber Phone Number
  • Prescriber Fax Number
  • Drug Name
  • Drug Dose
  • Drug Frequency


If available, please provide:

Formulary alternatives tried Diagnosis
**Please indicate whether or not the member’s health could be seriously harmed by waiting three days for a decision on this request.
**For members of Medicare Assured®, the prescribing physician or other prescriber must submit a statement to support the request for coverage determination.


There are several types of exceptions that you can ask us to make:

  • You can ask us to cover your drug even if it is not on our formulary.
  • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Gateway HealthSM Medicare Assured®  limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

Generally, Gateway HealthSM Medicare Assured® will only approve your request for an exception if the alternative drugs included on the plan’s formulary or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you are requesting a formulary or utilization restriction exception you should submit a statement from your physician supporting your request.  Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement.  Your physician must complete the Nonformulary Drug Exception Form (pdf).

 

What if my request for exception is denied?

You have the right to request a Reconsideration (redetermination) of this denial.  To do this, you may call Gateway HealthSM Medicare Assured®  at 1-800-685-5209 to file your request by phone or use the Request for Medicare Prescription Drug Coverage Determination Form (pdf) to file your request.  Your doctor may also make this request for you.  If you wish to have someone else make this request for you, you must include a completed Gateway HealthSM Medicare Assured® Appointment of Representative Form (pdf) to give this person permission.

If you wish to send us your request in writing, you may fax it to us at 412-255-4503.  You may hand deliver or mail your request to this address:

Gateway HealthSM
Attention: Medicare Complaints Administrator
Four Gateway Center
444 Liberty Avenue, Suite 2100
Pittsburgh, PA 15222-1222

You may also wish to refer to the Gateway HealthSM Medicare Assured® Evidence of Coverage for further details about the reconsideration process and further appeal options.

Forms require the Adobe Acrobat Reader installed on your system. Most computers have this program installed. If it is not installed on your computer, you can download it for free from Adobe.