Dear Marci,
My doctor prescribed a medication for my heart condition, but when I went to the pharmacy to pick it up, my pharmacist said that my plan would not cover it. I called my Part D plan and they told me that my drug was not on their formulary. What can I do?
-Logan (Tallahassee, FL)
Dear Logan,
A formulary is a prescription drug plan’s list of covered drugs. If your Part D plan told you that this drug was off-formulary, it means that your plan does not usually cover it. You do, however, have options to get your drug covered. You should speak with the provider who prescribed this medication.
Your provider may be able to prescribe a similar medication that is on your plan’s formulary. If your doctor believes that you need the off-formulary medication, because the available medications on the plan’s formulary would be unsafe or ineffective for treating your condition, ask your provider if they can assist you with an appeal to get the medication covered.
First, you or your doctor must file an exception request (a formal coverage request) with your plan. Contact your plan to learn how to file an exception request. Your provider should write a letter of support for your request. Your doctor may file on your behalf, but is not required to do so. You plan should issue a decision within 72 hours.
You can request a fast (expedited) exception request if you or your provider feel that your health could be seriously harmed by waiting the standard timeline for a decision. If your doctor supports your decision to file an expedited exception request, the plan must follow the expedited timeline. You can request an expedited exception request without your doctor’s support, but in this case, your plan does not have to follow the expedited timeline. If the plan grants your request to expedite the process, you will get a decision within 24 hours of the initial request.
If your exception request is approved, your drug will be covered. If your exception request is denied, your plan should send you a Notice of Denial of Medicare Prescription Drug Coverage. You have 60 days from the date listed on this notice to begin the formal appeal process by filing an appeal with your plan. This is true regardless of whether your appeal is under standard or expedited review. Follow the directions on the notice. If your doctor is not appealing on your behalf, you may want to ask your doctor to write a letter of support addressing the plan’s reasons for not covering your medication. Your plan should issue a decision within seven days, or within 72 hours if you are filing an expedited appeal.
If your plan approves your appeal, your drug will be covered. If your plan denies your appeal, there are several further levels of appeal you can pursue. Follow the instructions on the denial notice to learn how to appeal and where to send appeals materials. During the appeals process, you might pay out-of-pocket to get the drug our plan is denying. If you do this and later win your appeal, the plan should reimburse you. Keep receipts and submit them to your plan.
-Marci