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Medicare Part D: What Drugs Are Covered - The Formulary

Exceptions If A Drug Is Not On A Formulary

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If a drug is not on the Formulary, the company will not pay for it unless you request a special exception, and the company agrees to it.

Exceptions are not granted for drugs which are specifically excluded from Medicare coverage by law.

There is a right to an exception for drugs if either of the following occur:

  • Your doctor prescribes a drug which is not on your plan's formulary because your doctor believes the drugs on the plan's formulary will not work for you.
  • At the time when you sign up for a plan, you are taking a drug which is not on a Formulary.
  • You are using a drug covered by your plan, but that drug is removed from your plan's formulary for reasons other than because of safety.

Generally an exception is requested by your doctor, either orally or in writing since he or she has to certify that the drug prescribed is medically necessary and that other drugs are not as effective or may be harmful to you. Plans generally have to approve a request for an exception if it is deemed to be medically appropriate.

When asking for an exception, you can ask for an expedited review. If you do, your plan must respond with in 72 hours of the request for an exception, or within 24 hours or sooner if required for your health.

If the company refuses your request for a special exception, you can appeal. The appeal is to an independent review board. If you are still denied, you can ultimately request judicial review. To learn more about appeals, see: Medicare Advantage: How To Appeal. The procedures are basically the same.


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