Your Medicare Part D plan's Evidence of Coverage
(EOC) document will provide you with information about what you will pay for a
transition fill of a non-formulary drug.
You Evidence of Coverage is a large, printed document that you receive when first enrolling into a Medicare Part D plan and also receive each year with your Annual Notice of Change (
ANOC) letter that is mailed to you in late-September or early-October.
In your Evidence of Coverage document you should find some text such as:
"[i]f [the Medicare Part
D plan agrees] to make [a formulary exception] and cover a drug that is
not in the [plan's drug list], you will need to pay the cost-sharing
amount that applies to drugs in Cost-Sharing Tier 4 - Non-Preferred
drugs. You cannot ask for [another formulary] exception to [lower] the
copayment or coinsurance amount we require you to pay for the drug."
or you may read ...
"If we agree to make an exception and cover a drug that is not on the Drug List, you will need to pay the cost-sharing amount that applies to drugs in Cost-Sharing Tier 3: Non-Preferred Drug. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug."
This information should be found in a section entitled "What is an exception?", about 100 +
pages into the EOC document.
You can review our
Formulary Browser to see your plan’s cost-sharing for Tier 3 or Tier 4 or Tier 5 medications.
You can also telephone your Medicare drug plan's Member Services department and ask about the cost-sharing when a formulary exception is granted for the coverage of a non-formulary drug. The toll-free number for Member Services is found on your Member ID card.
Question: So, how much can you expect to pay for your transition fill of a
non-formulary drug if it listed as a Tier 3 or 4 Non-Preferred drug?
Probably around 25% to 50% of the non-formulary drug's retail cost. Your Medicare Part D
plan will charge you the
same cost-sharing amount as you would pay if a formulary exception
request had been granted and your non-formulary drug was being covered by your
Medicare Part D prescription drug plan.
As seen in the examples above, if your Medicare plan agrees to cover a
non-formulary drug, you may be asked to pay the cost-sharing associated
with Tier 3 or 4 Non-Preferred drugs - even when your non-formulary drug
is a low-costing generic. This means that you will be paying
a percentage of the drug’s retail cost (25% to 50% of retail).
For more information about the cost of a transition fill, please see our FAQ: "
How much will I pay for the transition fill of a non-formulary drug?"