• Home
• 7 Simple Steps
• Learn About Enrolling
• Review Current Coverage
• Learn About Costs
• Learn About Drugs Covered
• Drug Lists
• Payment Tiers
• Limits on Drug Use
• Exceptions to Limits
• Required Drugs
• Excluded Drugs
• Injectable Drugs
• Access to Pharmacies
• Switching Plans
• Find Extra Help Paying
• Get Personal Help

What if my drug is not on my plan’s drug list?

It is best to pick a plan that has all or most of your drugs on its drug list or formulary.  When you go to pick a plan, you may see that some plans cost more because they do not have your drugs on the list.

If you join a plan and find that one of your drugs is not covered, you can either:

• Switch to a similar drug that is on the plan’s formulary.
• Pay full price for the drug.  However, your costs for this drug will not count toward your out-of-pocket costs.

Or:

• You or your doctor can ask the plan for an exception.  If the plan approves, your payments for the drug will count toward your out-of-pocket costs.

When my drug is not on the list, what can I do?

You may be taking prescription drugs now that are not on your new Medicare Prescription Drug Plan’s drug list. Your plan must make sure that you can get the drugs you need. There are a number of ways your drug plan can help you switch or “transition” your drugs to the new plan.

They can give you a 30-day supply of the drug. This gives you and your doctor time to either

•  Switch you to one of the drugs the plan covers, or
• Ask for an exception or special permission so that your plan will cover your drug.

How do I ask for an exception?

You must call or write your plan and ask for the exception or special permission. Your doctor must also send a statement. It must say that the prescription drug you have asked for is medically necessary to treat your disease or condition. The plan would need to know what other drugs you've tried, how they worked, and how this one is working.

Can I pay less or get a higher dose?

You may ask if you can get a drug at a lower co-pay. This is important if your drug has a high co-pay. You may also ask if you can get more pills or a higher dose each month.

How long will it take for a decision?

The plan must let you know if it will cover the drug or if it will change your co-pay within 72 hours. If your doctor believes that waiting 72 hours for the drug is a risk to your health, the plan must let you know in 24 hours or less.

If my plan agrees to cover my drug, do I have to ask for an exception every time I get a refill?

No, once the plan says it will cover your drug, give you the amount you asked for, or give you a lower co-pay, you should get the drug under those terms for the rest of the enrollment year.  You should not need to ask again for the same drug.