Anyone enrolled in a Medicare Prescription Drug Plan (PDP) or a Medicare Advantage plan with drug coverage (MAPD), you may occasionally find that a medication prescribed by Their doctor is not covered by their drug plan. This is where a formulary exception can help. Right now you may be asking; what is a formulary exception?
A formulary exception is a formal request asking your Medicare drug plan to cover a medication that is not on its formulary (list of covered drugs) or to waive certain coverage restrictions. Here’s what you need to know about how formulary exceptions work and how to request one.
When do you need a Formulary Exception
We list below a few reasons why a Medicare beneficiary might need a formulary exception:
This is a common reason; the prescribed medication is not on the enrollee’s plan formulary. In other words, it isn’t covered. If the doctor believes it’s medically necessary, the enrollee can request an exception.
Some plans require enrollees to try lower-cost drugs (step-therapy)before covering a more expensive one. If the alternatives are ineffective or cause harm, the enrollee can request an exception.
In some cases, a plan may impose quantity limits on the medication beneficiaries receive within a specific time frame. If the doctor prescribes a larger amount than the drug plan covers, the beneficiary needs an exception.
If the necessary medication is on a higher-cost tier, beneficiaries can request a lower copay by asking the insurer to move it to a lower tier. This is referred to as a tier exception and it does not apply to specialty-tier drugs.
How to request a Formulary Exception
- The beneficiary should talk to their doctor to explain the situation. The doctor must provide a medical reason that the drug is necessary and why a lower cost alternative is not effective.
- The next step is to submit a formal request. The beneficiary must contact the drug plan and request a coverage determination. They should follow the official request process as explained by their plan provider and include supporting documents from their doctor.
- Once these steps are completed, the beneficiary waits for a decision. They should receive this within 72 hours of the request. If the enrollees health is at risk, they may request an expedited decision (within 24 hours).
- If the request is denied, the enrollee has the right to file an appeal. This process provides multiple channels for the beneficiary if they feel it is necessary.
Important takeaways
A formulary exception helps beneficiaries get coverage for medications that drug plans do not typically cover. Their doctor must provide medical justification for the request. In the event that the plan denies the request, the beneficiary can appeal the decision.
Watch a YouTube video on the $2,000 drug cap
Understanding formulary exceptions can help ensure beneficiaries receive needed medications and avoid unnecessary health risks.
Leave a Comment