Frequently Asked Questions about Formulary Exceptions (Coverage Determinations)

Aug, 08 2023 — A formulary exception is a type of coverage determination request whereby a Medicare plan member asks their Medicare Part D plan to cover a non-formulary drug or amend the plan's usage management restrictions that are placed on the drug.

Aug, 14 2023 — Yes. Although, Medicare Part D drug plans must continue to cover a medication dropped from the plan’s formulary until the end of the plan year for anyone using the particular medication, Medicare allows several exceptions when a drug plan can drop a formulary drug mid-year.

Jul, 10 2023 — Medicare Part D prescription drug plans can change their plan formulary or drug list throughout the plan year - and you may find that new Part D drugs are added - or dropped - or formulary drugs may h . . .

Jul, 25 2019 — No.  The Donut Hole discount only applies to medications that are included on your Medicare prescription drug plan’s formulary or drug list. If you wish to have your non-formulary medicati . . .

Jul, 12 2023 — Yes.  Medicare anticipates that Medicare Part D and Medicare Advantage plans will allow new plan members to file requests for formulary exceptions or coverage determinations before the beginnin . . .

Aug, 08 2023 — Yes, in some situations you have the right to ask your Medicare prescription drug plan to move a formulary medication to a lower-costing formulary tier. But, you cannot reduce the cost of a Tier 5 Specialty drug, nor can you reduce the cost of a now-covered, non-formulary drug.

Dec, 01 2019 — A Coverage Determination is any decision made by a Medicare Part D plan regarding payment or coverage benefits to which a Medicare plan enrollee believes he or she is entitled. More specifically, . . .

Jul, 19 2023 — An appeal is the process members can use when the plan makes a decision to deny coverage for a drug.  The member, the member's appointed representative, or, in some cases, the member's doctor can . . .

Sep, 08 2022 — Yes, your doctor can request an exception (or any other type of coverage determination) on your behalf.  In cases where delays may seriously affect your health, your doctor can also ask for an ex . . .

Jul, 28 2023 — Medicare Part D plans can change formulary or drug list designs each year and your Medicare prescription drug plan may have implemented utilization management (or drug usage management) restrictions i . . .

Mar, 13 2022 — No.  The Donut Hole discount only applies to medications that are included on your plan’s formulary. If you wish to have your non-formulary medication covered by your Medicare Part D pla . . .

Jul, 25 2023 — If one of your medications is not covered by your Medicare Part D prescription drug plan, there are at least three steps you can take: (1)  Ask for a temporary drug supply:   If you are . . .

Apr, 28 2023 — Probably not.  In some situations, you have the right to ask your Medicare Part D prescription drug plan (PDP or MAPD) to have a higher-costing drug moved to a lower-costing formulary tier and th . . .

May, 07 2023 — No. A Medicare Part D plan will not allow you to request a tiering exception for a drug (moving a drug to a lower-costing formulary tier) when your plan has just approved your formulary exception request to cover the non-formulary drug.

Jan, 23 2023 — Yes.  According to the Centers for Medicare and Medicaid Services (CMS), the transition fill policy will apply to both non-formulary Part D drugs and “Part D drugs that are on a sponso . . .

Jul, 10 2023 — The cost of covering a non-formulary drug will depend on your plan.  Your Medicare Part D plan has some flexibility with regard to what you will pay for the coverage of a non-formulary drug when . . .

Aug, 14 2023 — Yes. Although, Medicare Part D drug plans must continue to cover a medication dropped from the plan’s formulary until the end of the plan year for anyone using the particular medication, Medicare allows several exceptions when a drug plan can drop a formulary drug mid-year.

Aug, 08 2023 — Yes, in some situations you have the right to ask your Medicare prescription drug plan to move a formulary medication to a lower-costing formulary tier. But, you cannot reduce the cost of a Tier 5 Specialty drug, nor can you reduce the cost of a now-covered, non-formulary drug.

Aug, 08 2023 — A formulary exception is a type of coverage determination request whereby a Medicare plan member asks their Medicare Part D plan to cover a non-formulary drug or amend the plan's usage management restrictions that are placed on the drug.

Jul, 28 2023 — Medicare Part D plans can change formulary or drug list designs each year and your Medicare prescription drug plan may have implemented utilization management (or drug usage management) restrictions i . . .

Jul, 25 2023 — If one of your medications is not covered by your Medicare Part D prescription drug plan, there are at least three steps you can take: (1)  Ask for a temporary drug supply:   If you are . . .

Jul, 19 2023 — An appeal is the process members can use when the plan makes a decision to deny coverage for a drug.  The member, the member's appointed representative, or, in some cases, the member's doctor can . . .

Jul, 12 2023 — Yes.  Medicare anticipates that Medicare Part D and Medicare Advantage plans will allow new plan members to file requests for formulary exceptions or coverage determinations before the beginnin . . .

Jul, 10 2023 — The cost of covering a non-formulary drug will depend on your plan.  Your Medicare Part D plan has some flexibility with regard to what you will pay for the coverage of a non-formulary drug when . . .

Jul, 10 2023 — Medicare Part D prescription drug plans can change their plan formulary or drug list throughout the plan year - and you may find that new Part D drugs are added - or dropped - or formulary drugs may h . . .

May, 07 2023 — No. A Medicare Part D plan will not allow you to request a tiering exception for a drug (moving a drug to a lower-costing formulary tier) when your plan has just approved your formulary exception request to cover the non-formulary drug.

Apr, 28 2023 — Probably not.  In some situations, you have the right to ask your Medicare Part D prescription drug plan (PDP or MAPD) to have a higher-costing drug moved to a lower-costing formulary tier and th . . .

Jan, 23 2023 — Yes.  According to the Centers for Medicare and Medicaid Services (CMS), the transition fill policy will apply to both non-formulary Part D drugs and “Part D drugs that are on a sponso . . .

Sep, 08 2022 — Yes, your doctor can request an exception (or any other type of coverage determination) on your behalf.  In cases where delays may seriously affect your health, your doctor can also ask for an ex . . .

Mar, 13 2022 — No.  The Donut Hole discount only applies to medications that are included on your plan’s formulary. If you wish to have your non-formulary medication covered by your Medicare Part D pla . . .

Dec, 01 2019 — A Coverage Determination is any decision made by a Medicare Part D plan regarding payment or coverage benefits to which a Medicare plan enrollee believes he or she is entitled. More specifically, . . .

Jul, 25 2019 — No.  The Donut Hole discount only applies to medications that are included on your Medicare prescription drug plan’s formulary or drug list. If you wish to have your non-formulary medicati . . .