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How to Request a Coverage Determination or Formulary Exception.

To successfully request a formulary exception, you and/or your prescriber (generally your physician) must show that:
  • the requested medication is medically necessary, and

  • no other medication on your plan’s list of covered drugs (formulary) would work as well for you, especially if all other formulary drugs that are used to treat your condition would cause you to have a bad reaction.

What if my plan won’t cover a drug I think I need?

If your pharmacist tells you that your Medicare drug plan won’t cover a drug you think should be covered, or it will cover the drug at a higher cost than you think you are required to pay, you have the following two options:
  1. You can request a coverage determination if the drug is on your plan’s formulary, but your plan won’t cover it because it believes that you don’t need the drug. You can ask for a coverage determination before paying for the prescription. You can also pay for the prescription, save your receipt, and ask the plan to pay you back by requesting a coverage determination.

  2. You can request a type of coverage determination called an "exception" if:
    • you think your plan should cover a drug that’s not on its formulary because the other treatment options on your plan’s formulary will not work for you.

    • your plan requires you to get permission (prior authorization) before it covers a drug prescribed for you and you disagree.

    • you think your plan should charge a lower amount for a drug you are taking on the plan’s non-preferred drug tier because the other treatment options in your plan’s preferred drug tier won’t work for you.

    • your plan asks you to try another drug before it covers a drug prescribed for you (step therapy) and you disagree.

    • your plan has a limit on the number of pills or dosage for a drug prescribed for you (quantity limit) and you disagree.
Your prescriber must send a supporting statement explaining the medical reason for the exception. Plan Sponsor Exceptions & Appeals Contact Information Search

You cannot request an exception if:

How to Request a Coverage Determination or Exception

You, your doctor or other prescriber, or your representative can request that the plan cover the prescription you need. You may file either a standard request or an expedited (fast) request for your coverage determination or exception. Your request will be expedited if your plan determines, or your prescriber tells your plan, that your life or health may be at risk by waiting for a standard request. Your request won’t be expedited if you have already paid for and received the drug.

Tip: The plan must grant an expedited review if your doctor or other prescriber tells your plan that your life or health may be at risk by waiting for a standard request.

Your plan will need to know
  • Why no drug on the plan’s formulary (list of covered drugs) will work as well for you.

  • What other drugs you have tried and how they worked for you.

  • How the drug you want covered is working for you.
Without this information, your plan does not have to act on your request.

Coverage Determination Request Forms

You can write a letter or you can use the Member Model Coverage Determination Request Form or your prescriber can use the Physician Coverage Determination Request Form to ask your plan for a coverage determination or exception. You can get instructions for using these forms, copies of the forms and plan contact information below. Expedited requests may be filed over the telephone or in writing. Standard requests must be filed in writing, unless the plan accepts requests over the telephone.

Once your plan has received the request (and your physicians supporting statement if applicable), it has 72 hours (for a standard request for coverage) or 24 hours (for an expedited request for coverage) to notify you of its decision.

Tip: Any person you appoint, such as a family member, may help you request a coverage determination or file an appeal with your plan. Call your plan to learn how to appoint a representative.

In some cases, you might request a coverage determination before you pay for your prescription, but in some cases, you might decide to pay for the prescription, save your receipt, and request that the plan pay you back by requesting a coverage determination.

You (or your representative), your doctor, or other prescriber may request a coverage determination by following the instructions that your plan sends you. The plan will give you its decision within 72 hours. You, your doctor, or other prescriber can call or write your plan to request that an expedited (fast) decision be made within 24 hours. Your request will be expedited if your plan determines, or your doctor or other prescriber tells your plan, that your life or health may be at risk by waiting for 72 hours for a decision.

For some types of coverage determinations called "exceptions," you will need a supporting statement from your doctor or other prescriber explaining why you need the drug you’re requesting. You will need this statement for the following situations:
  • You’re requesting that the plan cover a drug that isn’t on its list of covered drugs (formulary).

  • You want the plan to cover a non-preferred drug at the preferred drug price.

  • Your doctor or other prescriber believes you can’t meet one of your plan’s coverage rules, such as quantity limits, prior authorization or step therapy.
Check with your plan to find out if the supporting statement is required and if it must be made in writing. If a supporting statement is required, the plan’s decision-making time period begins once your plan gets the supporting statement.

What if I Disagree with the Coverage Determination?

If your Medicare drug plan makes an unfavorable coverage determination decision, it will send you a written decision. If you disagree with your Medicare drug plan’s coverage determination or exception decision, you have the right to appeal.

Tip: When you join a Medicare drug plan, the plan will send you information about the plan’s appeal procedures. Read the information carefully and keep it where you can find it when you need it. Call your plan if you have questions.

Tips & Disclaimers
  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.