Dear Marci,
I recently went to my pharmacy, and my pharmacist told me that my prescription was not covered by my insurance. I asked my pharmacist how I might be able to get my prescription covered. She told me that I can appeal but before I start an appeal, she told me to ask for an exception request from my plan. What is an exception request?
– Nancy (Madison, WI)
Dear Nancy,
An exception request is a formal request made to yourstand-alone Part D plan or Medicare Advantage planthat asks the plan to make an exception to its normal rules and cover your drug. You must submit an exception request to your plan before starting the appeal process. If your exception request is denied, your plan will provide you with a written denial letter, which then allows you to start your formal appeal.
When your pharmacist told you your insurance would not cover your drug, you should have received a notice titled Medicare Prescription Drug Coverage and Your Rights. This notice provides a general set of options for you to potentially get your drug covered. This is not a formal denial notice. When you receive this notice, call your plan to ask why your drug was denied and share this information with your doctor who prescribed the drug. The drug may have been denied because it is not on your plan’s formulary, or because it has restrictionslike prior authorization, quantity limits, or step therapy. After reading this notice and speaking with your plan about the reason for denial, you should submit your exception request.
You can make your exception request over the phone or in writing, but it is recommended that you send your request to your plan in writing. You must include a letter from your doctor to your plan that states why you need this drug, and that the drugs on the formulary will not work as well for you or will harm you. This is called a letter of medical necessity. You also can include any medical records that support your request, such as lab reports or medical histories. Ask the plan representative you speak with if the plan has a form that it recommends you and your doctor use to submit the exception request. In addition, ask the representative for the plan’s address or fax number where you can send your written exception request.
You must specifically state what kind of exception you are requesting. You and your doctor may request that the plan covers a drug that is not on the plan’s formulary, or that the plan overrides a drug restriction, such as requiring step therapy before it will cover your drug.
Keep copies of all documents and records that you send to your plan. If you speak with a plan representative over the phone about the exception request, note the date, time, and representative’s name.
Your plan must issue a decision within 72 hours of receiving your exception request. Know that if it is an emergency and your health is in danger, your doctor can request a fast, or expedited, exception request. If your plan approves your exception request, your drug will typically be covered for the rest of the calendar year. If your plan denies your exception request, you should get a letter titled Notice of Denial of Medicare Prescription Drug Coverage, which explains how to begin a formal drug appeal.
-Marci