Avera Choice Plus Formulary

The amount you pay for your prescription depends on the drug's tier level and the benefit level shown on your Summary of Benefits and Coverage (see page 3).

• Prescription Reimbursement Claim Form for claims (pdf)

You can ask Avera Health Plans for an exception to the benefit coverage rules. To request a drug formulary exception:

1. Log in to the Avera Health Plans member portal and choose: My Pharmacy.
2. Click the link to request a drug formulary exception.
3. Complete the online form and submit.

For urgent requests, determination will be made no more than 24 hours after the request is received. For standard request, determination takes 72 hours.

Generally, we will only approve the exception request if you’ve tried alternative drugs available on the drug formulary and they haven’t been effective for treating your condition and/or would cause adverse side effects to you if you were to try them.

There are multiple reasons why a prescription may be declined. If you have questions, contact us so we can look into your records and provide an explanation for the pharmacy declining the request.