Navigating coverage for Part D prescription drugs can feel overwhelming, especially when your plan denies a medication you need.
Have you ever walked into a pharmacy to pick up a prescription, only to find out your Medicare Part D plan doesn’t cover it?
Fortunately, there are steps you can take to resolve this issue. These include requesting a Medicare Part D Prescription Drug Exception, filing an appeal, or exploring a new plan.
This guide will walk you through everything you need to know about what drugs are covered by Medicare Part D and how to make sure you get the medications you need without unnecessary stress.
Why Your Part D Prescription Drug Might Not Be Covered
Medicare Part D plans cover prescription drugs, but not every medication is included in every plan’s formulary (the list of covered drugs).
Your drug may be excluded for several reasons:
- It’s not on the formulary.
- It’s on the formulary but at a higher cost tier.
- The plan imposes usage restrictions like prior authorization or step therapy.
When this happens, you can request an exception or appeal the decision.
Understanding the process for Medicare Part D prescription drug exceptions can help you take the right steps to resolve the issue.
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Types of Exceptions for Part D Prescription Drugs
If your Part D plan doesn’t cover your medication, you can request one of two types of exceptions.
1. Formulary Exception
A formulary exception allows you to request coverage for a drug that isn’t on your plan’s formulary.
You will need to show that the drug is medically necessary and that alternatives on the formulary won’t work for you or could cause harm.
2. Tiering Exception
A tiering exception allows you to request that a medication on a high-cost tier be moved to a lower-cost tier.
To qualify, your doctor must confirm that no lower-tier drug can treat your condition as effectively.
How to Request a Part D Prescription Drug Exception
To improve your chances of approval for a Medicare Part D prescription Drug Exception, follow these steps:
1. Obtain a Doctor’s Supporting Statement
Your doctor must submit a statement explaining why the drug is medically necessary. This statement should include:
- Why formulary alternatives won’t work for your condition.
- Any adverse reactions you’ve had to alternative drugs.
- The expected benefits of the requested drug.
2. Get the Plan’s Request Form
Contact your Part D plan to obtain the specific form needed to request an exception. Most plans also provide instructions for how to submit the form.
3. Include Additional Medical Records
Your doctor may need to attach medical records to support the request.
4. Submit the Request
Send your completed form and documentation using the submission method specified by your plan (mail, fax, or online portal).
What Happens After You Submit the Exception Request?
Medicare Part D plans must respond to your request within 72 hours.
If your condition is urgent, you can request an expedited review, which shortens the response time to 24 hours.
- If approved: Your plan will cover your medication, and you’ll pay the applicable copay or coinsurance.
- If denied: You have the right to appeal the decision.
Steps to Appeal a Denied Exception
- Redetermination by your plan: File an appeal with your plan asking them to reconsider their decision.
- Review by an independent entity: If your plan denies the appeal, you can request a review by an independent entity through Medicare.
- Further appeals: If necessary, escalate the case to higher levels, including a hearing before an administrative law judge.
What Part D Prescription Drugs Are Covered?
Medicare Part D plans cover a range of prescription drugs, including:
- Brand-name drugs
- Generic drugs
- Medications for common medical conditions
However, each plan’s formulary is different.
To know exactly what drugs are covered by your Part D plan, check the formulary online or request a printed copy. This will help you understand your coverage and identify any potential issues before filling a prescription.
Consider Switching to a New Part D Plan
If your current plan consistently doesn’t cover the drugs you need, it might be time to switch.
During Medicare Open Enrollment (October 15–December 7), you can compare plans and choose one that better fits your medication needs.
How to compare Part D plans:
- Use the Medicare Plan Finder Tool to review each plan’s formulary.
- Compare premiums, deductibles, and copayments.
- Ensure your preferred pharmacies are in-network.
Switching to a plan that covers your prescriptions can save you time, money, and stress.
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Take Control of Your Medicare Coverage Today
Dealing with Part D prescription drug issues can feel overwhelming, but you don’t have to go through it alone.
A Personal Benefits Manager can guide you through submitting exception requests, appealing denials, and finding a better Part D plan. We are the only nationwide agency that can guide you through all three major options for managing Medicare’s out-of-pocket costs: Healthsharing, Medigap, and Medicare Advantage.
Let’s make sure you get the medications you need without unnecessary hassle. Contact us today for personalized assistance.
For Further Reading:
Christine Corsini is one of your Personal Benefits Managers at MediGap Advisors. She loves working for Medigap Advisors especially helping clients choose the right Medicare plan.