How to Obtain Medications Not Covered By Your Medicare Drug Plan

When choosing a Medicare Part D Drug Plan (usually during the annual Open Enrollment Period and between October 15th – December 7th) most do so based on their current medications. Frequently, however, over the course of the plan year medications are added or dropped. Consequently, a plan that once covered each of your medications may not later. Are you then stuck until the next Open Enrollment Period? Not necessary. Initially, the simplest approach may be to ask your doctor to prescribe another medication.

Talk to Your Provider

Often, there are many medications that achieve the same objective of your physician. If a drug isn’t covered ask your doctor for an alternative medication. If there isn’t an alternative drug available, then consider seeking a “drug formulary exception.”

Formulary Exceptions and Plan Determination Requests

An enrollee through his doctor can request a drug plan formulary exception to cover a medication. These exception requests are granted when a plan sponsor determines that a requested drug is medically necessary for an enrollee.

Generally, your doctor must submit a written request in support of the formulary exception. Your doctor needs to state the non-covered drug is medically necessary for treating for your condition because all other covered drugs would not be as effective. In the alternative, they must say you would have an adverse effect if other medications are required prior to initially prescribed drug (step therapy). While each plan may have individualized formulary request exception forms, Medicare has a Model Coverage Determination Request or standardized form that every plan must accept. See Medicare Model Determination Request Form

How a Plan Sponsor Processes an Exception Request

For enrollee benefit requests, such as formulary exception, once a plan sponsor receives a prescriber's supporting statement, it must provide written notice of its decision within 24 hours (for expedited requests) or 72 hours (for standard requests). The initial notice may be provided orally so long as a written follow-up notice is mailed to the enrollee within 3 calendar days of the oral notification. If the plan sponsor's coverage determination is unfavorable, the decision will contain the information needed to file a request for re-determination with the plan sponsor.