(1) Ask your Medicare Part D plan for a temporary drug supply.
If you are still in the first 90 days of your plan coverage, you may be able to ask your Medicare prescription drug plan for a one-time, transition fill or temporary 30-day supply of a medication you currently use. Remember, your medication cannot be a drug that is excluded from the Medicare program. To initiate a transition fill request, call the toll-free Member Services telephone number found on your Member ID card. Read more about what is required to get a transition fill.
(2) Search for an alternative formulary drug to replace your non-formulary drug.
While you are using your 30-day temporary medication supply (transition fill), you and your physician can look for an alternative medication (such as an equivalent generic or brand name drug) that is included on your Medicare Part D plan’s formulary (you can use our online Formulary Browser to review your plan’s drug list online).
Important reminder: Your transition fill is only for a 30-day supply of an existing prescription, so start working with your prescriber right away to find an alternative medication or file a formulary exception request.
(3) File a Formulary Exception request for coverage of a non-formulary drug.
If you are prescribed a new medication and you cannot find an alternative medication on your Medicare drug plan formulary, you can file a formulary exception request (a type of coverage determination) with your Medicare Part D plan. In essence you are asking that your non-formulary medication be covered by your Medicare plan - you are actually adding your non-formulary drug to your Medicare drug plan formulary.
Learn more about requesting a formulary exception and the prescribing physician’s role in the formulary exception request process.
Important: Formulary exception requests are not “automatically” granted.
If your formulary exception request is denied, you have the right to appeal your plan’s decision a number of times, ultimately with a review by an independent group. View an overview of the Medicare Part D appeals process.
(4) Consider changing to another Medicare drug plan with broader coverage using a Special Enrollment Period.
If you are outside of the the annual Open Enrollment Period (AEP - ending December 7th) or Medicare Advantage Open Enrollment Period (MAOEP - ending March 31, if enrolled in a Medicare Advantage plan), you may be able to use a Special Enrollment Period (SEP) to change Medicare Part D or Medicare Advantage plans during the year.
(5) Consider purchasing the non-formulary medication using a Drug Discount card.
If your 30-day transition fill has expired - and you cannot find an alternative medication on your plan's formulary - and your plan denied your formulary exception request to cover a non-formulary drug - and you are not interested in appealing your plan's negative formulary exception request decision - and you can't use the MAOEP or an SEP - you are able to use a drug Discount card or Drug Discount program (such as GoodRx or WellRx) to purchase your non-formulary (and formulary drugs when less expensive).
Related Questions:
- What will I pay for my medication if my Medicare plan agrees to cover a non-formulary drug?
- What should I do when my new drug is covered by my Medicare
drug plan, but I would like to reduce the price I am paying for the
drug: Can I ask my Part D plan to move my medication to a less expensive drug tier?
- If
my Medicare drug plan agrees to cover a non-formulary drug, can I also
ask the plan to move the same drug to a lower-costing formulary tier? Spoiler alert: No.
Source includes:
U.S. Department of Health & Human Services
https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Downloads/Parts-C-and-D-Enrollee-Grievances-Organization-Coverage-Determinations-and-Appeals-Guidance.pdf