Members: CareAdvantage: Exceptions, Appeals & Grievances

Exceptions, Appeals, and Grievances

A formulary exception is when HPSM agrees to cover a prescription that is not on the list of covered drugs, or to change the conditions for using a drug.

An appeal is a request for HPSM to rethink and change a decision to not cover a prescription drug or service, or a decision to not change the conditions for using a drug.

Follow these steps on How to request an exception or an appeal.

File a Grievance
Contact HPSM if you are not satisfied with a service or quality of treatment received from staff at your doctor’s office or HPSM.

Read more about How to file a grievance.

Reasons to request a formulary exception

You need a drug that is not on the CareAdvantage (HMO) list of covered drugs (formulary).
A drug that you have been using that used to be covered has been removed from the list of covered drugs for 2008.
You need a drug that your doctor has prescribed without being required to try another drug first.
The number of pills your doctor has prescribed is higher than the limit covered by the plan.
You think a prior authorization requirement for a drug your doctor has prescribed should be waived based on your condition.

Contact the CareAdvantage Unit for questions and assistance

1-866-880-0606 or 650-616-2174

Health Plan of San Mateo
701 Gateway Blvd. Suite 400
South San Francisco, CA 94080

Office hours
Monday through Friday
8 a.m. to 5 p.m.

Call center
Monday through Sunday
8 a.m. to 8 p.m.

(TTY) 1-800-735-2929 or dial 711
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