Frequently Asked Questions about Formulary Exceptions (Coverage Determinations)

May, 16 2024 — 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.

May, 24 2024 — 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, 19 2024 — 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, 02 2024 — 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, 05 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 January . . .

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 . . .

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, . . .

Jun, 04 2024 — An appeal is the process members can use when the plan makes a negative decision - such as when your plan denies coverage for a non-formulary drug (deny a Coverage Determination).The Medicare plan mem . . .

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 . . .

Apr, 20 2024 — 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 . . .

May, 10 2024 — Ask for a transition fill of your existing non-formulary drug, check for alternative drugs or generics covered by your Medicare drug plan, ask for a formulary exception covering the non-formulary drug, appeal any negative decisions, and finally use a Drug Discount card.

Jul, 19 2024 — Probably not. In some situations, you have the right to ask your Medicare Part D prescription drug plan to move a higher-costing drug to a lower-costing formulary tier. However, usually such a "tiering exception" is not available for plans with only one Specialty Drug

May, 02 2024 — 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 . . .

May, 02 2024 — The cost of covering a non-formulary drug will depend on your Medicare drug plan.  Your Medicare Part D plan has some flexibility with regard to what you will pay for the coverage of a non-formul . . .

Jul, 19 2024 — Probably not. In some situations, you have the right to ask your Medicare Part D prescription drug plan to move a higher-costing drug to a lower-costing formulary tier. However, usually such a "tiering exception" is not available for plans with only one Specialty Drug

Jul, 19 2024 — 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 . . .

Jun, 04 2024 — An appeal is the process members can use when the plan makes a negative decision - such as when your plan denies coverage for a non-formulary drug (deny a Coverage Determination).The Medicare plan mem . . .

May, 24 2024 — 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.

May, 16 2024 — 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.

May, 10 2024 — Ask for a transition fill of your existing non-formulary drug, check for alternative drugs or generics covered by your Medicare drug plan, ask for a formulary exception covering the non-formulary drug, appeal any negative decisions, and finally use a Drug Discount card.

May, 02 2024 — 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.

May, 02 2024 — 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.

May, 02 2024 — The cost of covering a non-formulary drug will depend on your Medicare drug plan.  Your Medicare Part D plan has some flexibility with regard to what you will pay for the coverage of a non-formul . . .

Apr, 20 2024 — 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 . . .

Dec, 05 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 January . . .

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 . . .

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 . . .

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 . . .