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How to Request a Coverage Determination or Formulary Exception.
:: Coverage Determination Request Forms
To successfully request a formulary exception, you and/or your prescriber (generally your physician) must show that:
- the requested medication is medically necessary, and
- no other medication on your plan’s list of covered drugs (formulary) would work as well for you, especially if all other formulary drugs that are used to treat your condition would cause you to have a bad reaction.
What if my plan won’t cover a drug I think I need?
If your pharmacist tells you that your Medicare drug plan won’t cover a drug you think should be covered, or it will cover the drug at a higher cost than you think you are required
to pay, you have the following two options:
- You can request a coverage determination if the drug is on your plan’s formulary, but
your plan won’t cover it because it believes that you don’t need the drug. You can ask for a coverage determination before paying for the prescription. You can also pay for the prescription, save your receipt, and ask the plan to pay you back by requesting a coverage determination.
- You can request a type of coverage determination called an "exception" if:
- you think your plan should cover a drug that’s not on its formulary because the other treatment options on your plan’s formulary will not work for you.
- your plan requires you to get permission (prior authorization) before it covers a drug prescribed for you and you disagree.
- you think your plan should charge a lower amount for a drug you are taking on the plan’s non-preferred drug tier because the other treatment options in your plan’s preferred drug tier won’t work for you.
- your plan asks you to try another drug before it covers a drug prescribed for you and you disagree.
- your plan has a limit on the number of pills or dosage for a drug prescribed for you and you disagree.
Your prescriber must send a supporting statement explaining the medical reason for the exception. Plan Sponsor Exceptions & Appeals Contact Information Search
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You cannot request an exception if:
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How to Request a Coverage Determination or Exception
You, your doctor or other prescriber, or your representative can request that the plan cover the prescription you need. You may file either a standard request or an expedited (fast) request for your coverage determination or exception. Your request will be expedited if your plan determines, or your prescriber tells your plan, that your life or health may be at risk by waiting for a standard request. Your request won’t be expedited if you have already paid for and received the drug.
Tip: The plan must grant an expedited review if your doctor or other prescriber tells your plan that your life or health may be at risk by waiting for a standard request.
Your plan will need to know
- Why no drug on the plan’s formulary (list of covered drugs) will work as well for you.
- What other drugs you have tried and how they worked for you
- How the drug you want covered is working for you.
Without this information, your plan does not have to act on your request.
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In some cases, you might request a coverage determination before you pay for your prescription, but in some cases, you might decide to pay for the prescription, save your receipt, and request that the plan pay you back by requesting a coverage determination.
You (or your representative), your doctor, or other prescriber may request a coverage determination by following the instructions that your plan sends you. The plan will give you its decision within 72 hours. You, your doctor, or other prescriber can call or write your plan to request that an expedited (fast) decision be made within 24 hours.
Your request will be expedited if your plan determines, or your doctor or other prescriber tells your plan, that your life or health may be at risk by waiting for 72 hours for a decision.
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For some types of coverage determinations called "exceptions," you will need a supporting statement from your doctor or other prescriber explaining why you need the drug you’re requesting. You will need this statement for the following situations:
- You’re requesting that the plan cover a drug that isn’t on its list of covered drugs (formulary).
- You want the plan to cover a non-preferred drug at the preferred drug price.
- Your doctor or other prescriber believes you can’t meet one of your plan’s coverage rules, such as a prior authorization, quantity limit, or dose limit.
Check with your plan to find out if the supporting statement is required and if it must be made in writing. If a supporting statement is required, the plan’s decision-making time period begins once your plan gets the supporting
statement.
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What if I Disagree with the Coverage Determination?
If your Medicare drug plan makes an unfavorable coverage determination decision, it will send you a written decision. If you disagree with your Medicare drug plan’s coverage determination or exception decision, you have the right to appeal.
Tip: When you join a Medicare drug plan, the plan will send you information about the plan’s appeal procedures. Read the information carefully and keep it where you can find it when you need it. Call your plan if you have questions.
:: How to Appeal a Coverage Decision
:: Appealing Medicare’s Late Enrollment Penalty
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