Requesting an exception for Medicare Part D formulary; Covering; The Bases

I was just prescribed a medicine that is not covered by my Part D plan because it is "not on their formulary." What does this mean, and what can I do?

All Medicare Part D plan have formularies. Simply speaking, a formulary is a list of covered medicines. If you do not already have a copy of your plan's formulary, contact your Part D drug plan and request a copy of their formulary. Present this formulary information to your doctor and ask if your doctor is willing to prescribe an alternative medicine that is covered by your Part D drug plan. This may resolve the problem.

However, your doctor may believe that it is in your best interest (medically speaking) to be on the medicine originally prescribed. If this is the case, contact your drug plan and request an "exception" for the particular medicine your doctor ordered.

An "exception" is simply requesting a drug plan cover a medicine that is not normally on their formulary. Be advised that most exception requests require the prescribing doctor to complete a portion of the form documenting why it is medically necessary to be on the medicine.

An exception request may be filed as either a standard request or as an expedited request. A standard request could take up to 72 hours for a determination to be made. You may file an expedited request if your doctor states that your life or health may be at risk if the request is not processed within 24 hours.

Please note, if you have already paid for the medicine, your request will not be handled as an expedited request - it will be handled as a standard request. There is no guarantee that the plan will grant you an exception. However, if the exception request is denied, you can appeal the decision. Your drug plan will provide information on filing an appeal.

I was prescribed a very expensive medicine. My Part D drug plan covers the medicine, but the co-payments are outrageous. My income, while modest, is above any threshold for subsidies to pay for medicines. Is there any recourse?

Medicare Part D drug plans are allowed to price their medicines according to tiers. The least expensive drugs, typically generic medicines, are classified as Tier 1 medicines. Tier 1 medicines have the lowest co-payment amounts. The more expensive medicines are classified as higher tier medicines and have higher co-payments.

Each Part D drug plan sets its own tiers and co-payment amounts. Each plan can change its cost tiers from year to year. Contact your Part D drug plan to see what tier your medicine is designated.

You may be able to request a "tier exception" to have your particular medicine priced lower due to medical necessity and/or financial hardship. Your plan can provide more guidance on how to request a tier exception.

There are certain tiers that federal law protects from a tier exception request. If your medicine has been designated as a "specialty tier," then your Part D drug plan will not consider a request for a lower co-payment. Typically, a specialty tier medicine is a very expensive medicine.

To prevent a Part D drug plan from designating all expensive medicines as a specialty tier, there are strict rules to which a Part D drug plan must abide. The Centers for Medicare and Medicaid Services is the federal agency that runs Medicare. CMS must approve a drug plan's request to place drug into a specialty tier.

Amy Rubino is the director of the Senior Health Insurance Assistance Program and the Senior Medicare Patrol for the Anne Arundel County Department of Aging and Disabilities. You may contact either program at 410-222-4257 or ship_program@aacounty.org.

Credit: Amy Rubino - Amy Rubino is the director of the Senior Health Insurance Assistance Program and the Senior Medicare Patrol for the Anne Arundel County Department of Aging and Disabilities. You may contact either program at 410-222-4257 or ship_program@aacounty.org.