EXCEPTIONS AND APPEALS

What if the needed medication is not on the Medicare PDP’s formulary?

Dual eligibles have the right to request that their PDP covers a medically necessary drug not on the plan’s formulary when:

·        the drug is removed from the PDP’s formulary for reasons other than safety, and

·        the doctor prescribes a drug that is not on the PDP’s formulary, but believes the drugs available on the PDP formulary will not meet a dual eligible’s needs.

Who can request an exception?

A dual eligible, their legally authorized representative, or their prescribing physician can request an exception by contacting the plan.  The pharmacist who tells you that your medication is not covered by your plan does not affect a coverage determination which can only be made by the plan.  Network pharmacists will post or distribute general notices to tell beneficiaries to contact their PDP for a coverage determination or to request an exception.   

How is a request for an exception to the PDP formulary made?

Once it is realized that a drug is not covered, it is important to contact the PDP to request an exception. An oral or written supporting statement from a doctor demonstrating the drug’s need is necessary. Generally, PDPs must grant these exception requests when making a determination that it is medically appropriate. PDPs must respond to requests within 72 hours.

What if medication is needed sooner than 72 hours?

A faster response (an expedited request) can be made when “life, health or ability to regain maximum function” is in jeopardy.  PDPs must respond to expedited requests within 24 hours. If a PDP denies an exception request, an appeal of its decision can be made.

Will a request for an exception be necessary every time a medication refill is made?

No, if a PDP grants a request, the exception must continue to cover refills as long as:  1) the doctor continues to prescribe that drug; 2) the drug continues to be safe, and 3) the calendar year has not expired.

Can an exception for excluded drugs be requested?

No, exceptions for drugs specifically excluded from Medicare prescription drug coverage, such as a benzodiazepine, cannot be requested.

What if the exception request is denied?

An appeal can be made. The appeals process includes a second review by the plan, a review by an independent review entity, an administrative law judge review and, finally, consideration by the Medicare Appeals Council.