Each Medicare private drug plan will have its own list of covered drugs (Formulary). As your search has proved, you may not be able to find a plan that covers all your medications, or you may find one that does now but then get a new prescription that isn’t on the formulary.
Fortunately, you have rights under the new drug benefit that provide some measure of protection that you will get the medicines you need. You have the right to request that your plan cover a “medically necessary” drug that is not on its formulary when:
- Your doctor prescribes a drug not on your plan’s formulary because your doctor believes the drugs on the plan’s formulary will not work for you or would be harmful;
- You are using a drug that is currently covered by your plan, but that drug is removed from your plan’s formulary for reasons other than safety.
Note: You cannot ask for an exception for drugs specifically excluded from Medicare coverage by law. While Medicare will not pay the plan for these drugs, some plans may choose to cover them. Some state Medicaid programs may also cover the cost of these drugs.
If you join a plan that does not cover a drug you need ask the plan about its transition plan. All plans must have a transition process to help new members switch to covered drugs. These processes will vary by plan, but could include coverage of a one-time refill of your drug or attempts to explore substitutions with you and your doctor before the new coverage is effective. To obtain long-term coverage of your medication, however, you will probably need to ask for an exception to the plan’s formulary.
Contact the plan to request an exception to its formulary. (You, someone you appoint, your legal guardian or your prescribing doctor can file an exception.) You will then need to get your doctor to tell the plan in writing or by the phone why you need this particular drug. Generally, plans must grant these requests for coverage – called exceptions- when you can show that it is medically appropriate that they do so.
Plans do not have to cover your drug while you are waiting for a response. However, they must respond to your request within 72 hours. You can also ask for a faster response by filling an expedited request. To qualify for this type of request, your doctor must certify that your “life, health or ability to regain maximum function” is in jeopardy. Plans must respond to an expedited request within 24 hours.
If a plan grants your request, it will tell you how much your co-payment will be for the drug. The plan must continue to cover refills for the rest of the calendar year as long as the doctor continues to prescribe that drug (unless there is evidence the drug is unsafe). When a new calendar year starts, you may have to ask for another exception.
If a plan denies your exception request, you can appeal the plan’s decision. The appeals process for Medicare drug coverage is similar to the appeals process for denial of care from a Medicare health private plan (like an HMO or PPO).