Contraceptive Tier Exception Request for Members

Your doctor may want to prescribe a medication or another FDA-approved contraceptive agent that is not covered under Florida Blue’s prescription formulary/medication guide.

If this is the case, either you or your doctor can request an exception by submitting a Contraceptive Tier Exception Request.

How to submit a Contraceptive Tier Exception Request for medications or other contraceptive agents under a pharmacy benefit:

• Use the Contraceptive Tier Exception Request form. Submit an electronic request via CoverMyMeds or complete the form and fax it to Prime Therapeutics at 1-855-212-8110. Please be sure to provide all necessary medical records and documentation required for us to determine an exception for medical necessity. If you have questions about which form to use, call the number on the back of your member ID card.

Prime Therapeutics will review and then approve or deny your Contraceptive Tier Exception Request within 72 hours (urgent requests) or 15 calendar days (non-urgent requests). We’ll notify you and your doctor with the result by letter.

If the request is denied, you or your doctor can appeal. To do so, submit a completed appeal form based on your benefit. Please allow 30 days for appeals to be reviewed.

• HMO Member Grievance and Appeal Form
• Non-HMO Member Grievance and Appeal Form

Have questions? We’re here to help. Call us at the number on the back of your member ID card.