A formulary exception is a type of coverage determination request whereby a Medicare plan member asks for an exception to their Medicare Part D plan coverage rules. For example a Medicare plan member has the right to ask 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 (for example if the plan has a 30 pill per 30 day quantity limit, you might ask for a formulary exception of 60 pills per 30 days).
Similar to a formulary exception request is a plan member's right to ask that their drug plan move a formulary drug to a lower-costing drug tier (for example, if your drug is now listed on the plan's formulary as Tier 3, you can ask the plan to cover the drug on a Tier 2 cost-sharing level.)
Q1Medicare.com has an entire section dedicated to Formulary Exceptions (Coverage Determinations), Appeals & Grievances, but here are some highlights with links below.
All Medicare Part D drug plan members have the right to ask for certain Coverage Determinations and all Medicare drug plans must have a timely and efficient process for
making Coverage Determination decisions, including decisions on
exception requests. In short, the Coverage Determination (formulary and tiering exception) process is a fast, straightforward way to make sure people with Medicare can get the drugs they need. Through the formulary exception process, a Medicare Part D plan member may be able to:
Generally, plans must approve exceptions when they find that the drug is medically necessary, consistent with the supporting information provided by the member's doctor.
For more information, you can learn more about formulary exception at the following links: