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FAQs on Formulary Exceptions (Coverage Determinations)



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Category: Formulary Exceptions (Coverage Determinations)


Most Viewed FAQs in Category
What is a Formulary Exception?
A formulary exception is a type of coverage determination request.  All Medicare drug plans must have a timely and efficient process for making coverage determination decisions, including decisio . . .

I use a brand-name drug, but it is not covered by my Medicare Part D plan. Will the 50% discount on brand-name drugs still apply to this drug when I am in the Donut Hole?
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 . . .

Can I ask for a formulary exception before the start of the new coverage period that starts in January?
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 beginning . . .

What should I do if my brand-name medication is dropped from my Medicare drug plan?
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 . . .

Can my doctor ask for an exception on my behalf?
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 . . .

What is an Appeal?
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 . . .

Once I join a Medicare Part D plan and I am locked-in for the year, can my Medicare prescription drug plan drop medications from its drug list?
Yes. Your Medicare Part D prescription drug plan's formulary or drug lists can change throughout your coverage year - with approval from CMS (the Centers for Medicare & Medicaid Services).  H . . .

What is a coverage determination?
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, . . .

I use a brand-name drug, but this medication is not covered by my Medicare Part D plan. Will the brand-name discount still apply to this drug when I am in the Donut Hole?
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 . . .

I stayed with the same Medicare Part D plan as last year and now see that some of my medications are subject to Quantity Limits, Prior Authorization, and Step Therapy. What does this mean?
Medicare Part D plans can change formulary or drug list designs each year and with the new plan year, your Medicare prescription drug plan may have implemented utilization management (or drug usage ma . . .

Newest FAQs in Category
Can I ask for a formulary exception before the start of the new coverage period that starts in January?
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 beginning . . .

Can I ask my Medicare Part D plan to move my expensive medication to a lower-costing formulary tier?
Maybe - depending on the drug.  Asking your Medicare Part D prescription drug plan to move a formulary medication to a lower-costing formulary tier (for example, from a Tier 4 medication to a Tie . . .

Can I ask my Medicare drug plan for a formulary exception lowering the coverage cost of my Tier 5 Specialty Drug.
No.  You should find that your Medicare Part D plan Evidence of Coverage (EOC) document states: “Drugs of our [insert name of specialty tier] are not eligible for this type of exception [a . . .

I stayed with the same Medicare Part D plan as last year and now see that some of my medications are subject to Quantity Limits, Prior Authorization, and Step Therapy. What does this mean?
Medicare Part D plans can change formulary or drug list designs each year and with the new plan year, your Medicare prescription drug plan may have implemented utilization management (or drug usage ma . . .

Once I join a Medicare Part D plan and I am locked-in for the year, can my Medicare prescription drug plan drop medications from its drug list?
Yes. Your Medicare Part D prescription drug plan's formulary or drug lists can change throughout your coverage year - with approval from CMS (the Centers for Medicare & Medicaid Services).  H . . .

I use a brand-name drug, but it is not covered by my Medicare Part D plan. Will the 50% discount on brand-name drugs still apply to this drug when I am in the Donut Hole?
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 . . .

What should I do if my brand-name medication is dropped from my Medicare drug plan?
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 . . .

What is a Formulary Exception?
A formulary exception is a type of coverage determination request.  All Medicare drug plans must have a timely and efficient process for making coverage determination decisions, including decisio . . .

I use a brand-name drug, but this medication is not covered by my Medicare Part D plan. Will the brand-name discount still apply to this drug when I am in the Donut Hole?
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 . . .

What if I need a drug that is not on the Medicare plan formulary or is covered at a higher cost?
If you need a drug that is not on your Medicare Part D plan's covered drug list, or that is on the formulary - but you think it should be covered for a lower copayment, you can do the following: . . .






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