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What if I’m taking a drug that isn’t on my plan’s drug list when my drug plan coverage begins?

Your drug plan will provide a one-time, temporary 30-day supply of your current drug during your first 90 days in a plan. Plans are required to give you this temporary supply so that you and your doctor have time (30 days) to find another drug on the plan’s drug list that will work as well as the drug you are taking now. Different rules may apply for people who move into an institution (such as a nursing home or long-term care hospital).

However, if you have already tried similar drugs on your plan’s drug list and they didn’t work, or if your doctor determines that you need a certain drug because of your medical condition, you or your doctor can contact your plan to request an exception as soon as you get your temporary 30-day supply. You can also request an exception if your doctor thinks you need to have a coverage rule waived, such as a dose or quantity limit. If you or your doctor’s request is approved, the plan will cover the drug. If your plan doesn’t approve the exception, you can appeal the plan’s decision. For more information on appeals, see pages 58–60 (How to Appeal).



(Primary Source: Centers for Medicare and Medicaid Services - Your Guide to Medicare Prescription Drug Coverage 2008. This content may have been enhanced by Q1Group LLC to include further examples, explanations, and links.)


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