With an exception, your plan gives you special permission to have a prescription drug covered that your plan would not normally cover. You would ask your plan for this exception. An exception means that you are asking your plan to make a special change just for you to its rules about drug coverage. Exceptions are sometimes called “coverage determinations.”
When can I ask for an exception?
- if you need to get a drug that is not on your Part D plan's drug list, OR
- if you need a drug that your plan has set limits on or has special rules about, OR
- if a drug you need costs more than you can afford.
NOTE: You cannot ask your plan for an exception if the drug you need is not covered by law, or if it is on what is called a “specialty tier” in terms of cost. But you may still be able to apply for extra help with your Medicare prescription drug costs if you have limited income and assets.
Your Part D plan may give you an exception if you and your doctor can show that:
- the drug you need is medically necessary AND
- no other drug on your plan's list of covered drugs would work as well for you — especially if all the other drugs on the plan's list of covered drugs that are used to treat your condition would cause you to have a bad reaction.
Who can ask for an exception?
You, your doctor, or someone else you ask to help you can request an exception. But even if you do it, your doctor will need to tell the plan the medical reasons why you need a specific drug. The doctor must also tell the plan why no drug on the plan's list of covered drugs, or formulary, will work as well for you. The plan will need to know what other drugs you have tried, how they worked, and how the drug you want is working for you. Without this information, your plan does not have to act on your request.
The doctor can give this information to your plan on the phone or in writing.
If you ask someone who is not your doctor to help you, such as a friend or relative, you and that person must sign a written statement that you want the help and give it to your plan.
How long does it take to get an exception?
This process moves quickly. If you request an exception, your plan must make a decision within 72 hours, or 3 days. The decision can be made even faster – within 24 hours — if your doctor believes that waiting 72 hours would cause serious harm to your health. If that is the case, then your doctor must ask the plan to “expedite” your request.
Do I need to fill out a special form to ask for an exception?
Yes. Your plan may have its own form for exceptions. Check with your plan to see if you need a specific form to file an exception.
You can also use Medicare’s standard coverage determination request form. Only you or someone other than your doctor may use that form.
If your doctor is asking for an exception for you, he or she can useMedicare’s standard coverage determination request form for physicians.
If you need an answer right away, your doctor can fax or call your plan with an expedited exception request. You do not need a special form.
What happens next?
If your plan approves your exception request — for example, it says it will cover your drug, or give you the amount of the drug you asked for, or give you a lower copay. You should be able to fill your prescription for this drug within 72 hours of when the plan approves your exception.
If the plan approves your request, you should also get the drug under those terms for the rest of the calendar year. You should not need to ask again for the exception that year. However, at the end of the calendar year, you should check with your plan to see if you will need to make a new exception request for the following year.
If the plan approves your request, the costs for the drug will also count toward your out-of-pocket costs.
If your plan denies your exception request, you can file what is called an appeal.
NEXT: What is an appeal?