CurrentQualChoicePolicy N/A

Formulary override / external review for non-formulary drugs

Describes how members or their designees can request coverage or an external review for non-formulary prescription drugs and the documentation required for approval; applies to QualChoice members in North Carolina.

Policy Summary

PayerQualChoice

PolicyFormulary override / external review for non-formulary drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed QualChoice General Pre-Authorization Form with documentation of trials of all formulary alternatives (or explanation why trials are not possible).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

800-753-2851Initial request phone

877-251-5896Initial request fax

800-235-7111External review phone

833-681-2498External review fax

Trials of formulary alternativesDocumentation required

Formulary Exception and External Review Criteria

Formulary exception and external review process

To request coverage or appeal a denial for a non-formulary drug:

Request must be made by the member, someone appointed by the member, or the prescribing physician.

Who may request: member / appointed representative / prescribing doctor

Submit the completed QualChoice General Pre-Authorization Form.

Include required documentation described below

Initial contact for a formulary exception: call 800-753-2851 or fax the completed form to 877-251-5896.

Approval requires documentation of adequate trial(s) of ALL formulary alternatives, or documentation explaining why such trial(s) are not possible; the prescriber must provide this documentation with the completed request form.

Policy Summary

PayerQualChoice

PolicyFormulary override / external review for non-formulary drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed QualChoice General Pre-Authorization Form with documentation of trials of all formulary alternatives (or explanation why trials are not possible).

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

How to Request a Formulary Exception or External Review

Prior Authorization

Initial formulary exception request

To request a formulary exception for a non‑formulary drug, the prescriber or someone the member appoints may call QualChoice at 800-753-2851 or fax the completed QualChoice General Pre-Authorization Form (PDF) to 877-251-5896. Include the drug name, member information, prescriber name, and documentation of prior trials or rationale why trials are not possible.

Include: drug name, member name, member ID, prescriber name, member signature, date

Denial Risk

External (outside) review after denial

If the initial exception request is denied, the member, someone appointed by the member, or the prescribing doctor may request an external (outside) review by an independent review organization. To request an external review call 800-235-7111 or fax the completed external review request form to 833-681-2498. The completed form must indicate who is requesting the review (member, appointee, or prescribing doctor) and must include the denied drug name and all supporting documentation.

Call 800-235-7111 to initiate an external review
Fax the completed external review request form to 833-681-2498
Form must state who is requesting the review (Member / Appointee / Prescribing doctor)

Documentation Required

Documentation requirement for approval

Approval of a formulary exception requires documentation of adequate trial(s) of ALL formulary alternatives or a clear justification why such trials are not possible. Provide this documentation with the initial exception request or with the external review request form.

Document trials of all formulary alternatives or explain why trials cannot be completed
Attach supporting clinical records and rationale to the submitted form

Key Definitions

Formulary exception — definition / short description

TermFormulary exception

DefinitionRequest to override the formulary to obtain coverage for a non‑formulary (non‑covered) prescription drug.

Who may requestMember, someone appointed by the member, or the prescribing doctor may submit the request.

How to submitSubmit the completed QualChoice General Pre‑Authorization Form with required documentation (see documentation requirement).

Approval requirementApproval requires documentation of adequate trial(s) of ALL formulary alternatives or documentation why such trials are not possible.

Outside reviewer / independent review organization — definition / short description

TermOutside reviewer / independent review organization

DefinitionAn external (outside) reviewer or independent review organization that performs a second review when a formulary exception request is denied.

When to requestIf the initial formulary exception request is denied, the member may request a second review by an external reviewer.

How to requestCall 800‑235‑7111 or fax the completed form to 833‑681‑2498 to initiate the external review.

Who may requestMember, someone appointed by the member, or the prescribing doctor may request the external review.