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Exceptions

You and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your provider says that you have a medical reason that would justify asking the plan for an exception, your provider can help you request an exception to our utilization management tools; such as prior authorization, quantity limits, or step therapy requirements. You can ask the plan to cover a drug even though it is not on the plan's drug list, or you can ask the plan to cover the drug without restrictions.

What is an exception?

You or your doctor may ask the plan to make an exception to its Part D Coverage Rules in a number of circumstances, for example:

  • Covering a Part D drug for you that is not on the plan's List of Covered Drugs (Formulary): called the “Drug List” for short. Asking for coverage of a drug that is not on the Drug List is sometimes called asking for a formulary exception.
  • Removing a restriction on the plan's coverage for a covered drug. There are extra rules or restrictions that apply to certain drugs on the plan's List of Covered Drugs (Formulary).
    • Getting plan approval in advance before the plan will agree to cover the drug for you. (This is sometimes called “prior authorization.”)
    • Being required to try a different drug first before the plan will agree to cover the drug you are asking for. (This is sometimes called “step therapy.”)
    • Quantity limits. For some drugs, there are restrictions on the amount of the drug you can have.

Asking for removal of a restriction on coverage for a drug is sometimes called asking for a “formulary exception.”

  • If your drug is in a cost-sharing tier you think is too high, start by talking with your provider. Perhaps there is a different drug in a lower cost-sharing tier that might work just as well for you. You can call the Member Services Department to ask for a list of covered drugs that treat the same medical condition. This list can help your provider find a covered drug that might work for you.
  • Asking to pay a lower preferred price for a covered non-preferred drug is sometimes called asking for a “tiering exception.”

Request for Medicare Prescription Drug Coverage Determination (English Spanish)

 

Last Updated: 
October 1, 2017