There are times that a medication isn’t covered under a Medicare part D plan’s formulary. It is during those times that Medicare part D exceptions can be requested. Medicare part D exceptions are normally formulary exceptions that are requested by the member or the member’s doctor. With so many medications that aren’t covered under Medicare’s original formulary, these exceptions aren’t uncommon.
The Medicare part D exceptions process is very simple to start. When a member goes to have a prescription filled, they may be denied for different reasons. Some medications just aren’t on the formulary because they are not a Medicare approved medication. Others find the pricing of their medication to be too expensive due to the tier it’s on and members want it to fall under a different tier. When these things happen, a member or their doctor has the right to call the Medicare part D provider and request an exception be made for that member.
Tier and Formulary Exceptions Explained
Medications are very important and there are times that exceptions have to be made. When a member is prescribed a medication that is not on the formulary or is categorized on a higher tier than expected they have the right to request an exception be made. There are two common kinds of Medicare part D exceptions heard and approved all the time: tier exceptions and formulary exceptions.
A tier exception happens when a non-preferred medication is prescribed and is placed on a tier higher than the preferred medication, making it harder for the member to pay for. When a medication is placed on a higher tier, the out of pocket cost of that medication may make it harder for the member to continue their prescribed treatment. Instead of constantly paying that higher price, members can ask the Medicare part D exceptions process be started.
Formulary exceptions normally happen when a member goes to the pharmacy and the pharmacy informs them their medication isn’t covered under their insurance. Medications that are not Medicare approved are normally denied by the insurance provider. If a medication is Medicare approved, it may not be covered under that particular plan’s formulary. Instead of paying the retail price for the medication, many members ask their insurance to start the exceptions process.
The Medicare Part D Exceptions Process
When the Medicare part D exceptions process starts, it can go very fast. Members don’t always expect it to be finished within 72 hours. Because this can be a matter of life and death, Medicare part D providers don’t waste time in processing these requests.
Members that choose to go through the Medicare part D exceptions process have to contact their doctor and request supporting documents. This is normally a letter or statement from the doctor stating that the medication is medically necessary as written. There are often questions of what happens if an alternative medication is taken or why the medication has to be taken so many times per day that have to be answered by the doctor. The doctor can give this information over the phone but it should be followed up in writing.
Once all the necessary paperwork has been submitted, most members can expect a result within 72 hours. For those that have an expedited request, an answer can be expected within 24 hours of the Medicare part D plan hearing from the doctor.