Sometimes our members need access to pharmacy benefit drugs that are not listed on the plan's formulary (drug list). These medications are initially reviewed by the formulary exception review process administered by WellFirst Health — Provided by SSM Health Plan's full-service pharmacy benefit company, Navitus Health Solutions. The member or provider can submit the request to us by faxing the Member Exception to Coverage Request form to 855-668-8551.
To request an expedited review, you must identify in writing on the form that your request should be expedited.
For additional details see the process created and maintained by Navitus.
If the pharmacy benefit drug is denied, you have the right to an external review. If you feel we have denied the non-formulary request incorrectly, you may ask us to submit the case for an external review by an impartial, third-party reviewer known as an Independent Review Organization (IRO). We must follow the IRO's decision. An IRO review may be requested by a member, member's representative, or prescribing provider by mailing, calling, or faxing the request form:
Illinois Departments of Insurance
Office of Consumer Health Insurance External Review Unit
320 W. Washington Street
Springfield, IL 62767
(877) 850-4740 Toll-free phone
(217) 557-8495 Fax number
For standard exception review of medical requests where the request was denied, the timeframe for review is 72 hours from when we receive the request. For expedited exception review requests where the request was denied, the timeframe for review is 24 hours from when we receive the request.
This information pertains only to our QHP plans.