If your Medicare drug plan won't cover a drug you need, or charges a high tier price for it, you or your prescriber can ask the plan for an exception. Your prescriber must send a statement explaining the medical reason the exception should be approved. If the plan says no, you can appeal within 65 days of the denial notice, and you can ask for a fast decision if waiting could seriously harm your health.
What is a formulary?
A formulary is your plan's list of covered drugs. Medicare's guide to drug coverage says each plan can cover different drugs, so there's no single list for all plans. Plans can also:
- Put drugs into different tiers, with different costs.
- Use coverage rules like prior authorization, step therapy, and quantity limits.
- Change the drug list during the year, if they follow Medicare's rules.
What kinds of exceptions can I ask for?
Medicare's guide describes these:
- Formulary exception: asking the plan to cover a drug that isn't on its list. The guide says if you or your prescriber believe none of the drugs on the list will work for your condition, you can ask for an exception.
- Tiering exception: if your drug is in a higher tier and your prescriber thinks you need it instead of a similar drug in a lower tier, you can ask for a lower copay or coinsurance.
- Prior authorization exception: asking the plan to cover the drug even if you don't meet its prior authorization requirements.
- Step therapy exception: asking to skip trying a less expensive drug first.
- Quantity limit exception: asking for more than the plan's usual limit.
What does my prescriber need to send?
Medicare.gov says that if you ask for an exception, your prescriber must give a statement explaining the medical reason it should be approved.
The Centers for Medicare & Medicaid Services (CMS) says that once your plan gets your prescriber's supporting statement, it must give you its decision within 72 hours for a standard request or 24 hours for an expedited (fast) request. The clock starts when the plan gets the statement.
For prior authorization and step therapy exceptions, Medicare's guide says the statement should include the prescriber's belief that:
- Because of your medical condition, the drug is medically necessary.
- You would have negative health effects with a different drug, or a different drug would be less effective.
How do I ask for an exception?
Medicare.gov says you can:
- Send a completed "Model Coverage Determination Request" form, or
- Write your plan a letter.
You can also ask by phone. Medicare.gov says you have the right to a coverage determination either orally or in writing. Your prescriber can also ask for you.
Ask your plan for its own form if it has one. Keep a copy of everything you send.
What if I need the drug right away?
If waiting for a standard decision could seriously jeopardize your health, ask for a fast (expedited) decision. Your prescriber can tell the plan it's urgent.
What is a transition fill?
Medicare's guide says that when your drug coverage begins, you may get a transition fill: a one-time 30-day supply of a drug you've been taking that your new plan either doesn't cover or requires prior authorization or step therapy for. This gives you time to ask for an exception or switch drugs.