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Medicare Part D Exceptions and Appeals

You may have trouble getting a prescription covered by a Medicare Part D plan for several reasons. The most common reasons are:

Your drug is not on the list of drugs your plan will cover, called the "formulary" or
There are restrictions on the medication (like prior authorization, step therapy or quantity limits)

If you have trouble getting your medication, it is always best to:

1. Talk to your doctor about the problem. There may be another medication on your formulary that you can take. Your doctor can also help you ask the plan to cover your medication even if there are restrictions or if the medication is not covered on the formulary.

2. Talk to your prescription drug plan. Every plan has a system for processing "exceptions" to its list of covered drugs or any restrictions on medications. Your plan must help you through this process.

Click here for a Medicare Part D exceptions and appeals - do it yourself guide for Medicare beneficiaries and the people who help them

Your plan may have a form to fill out if you want to request a medication that is not on the formulary or to request the plan cover your medication without restrictions.

Some sample forms are included in the do it yourself guide, above.

If these strategies fail, you may be able to change to another plan that covers your medication. You can change plans:

Monthly if you have Medicaid or if you have a Medicare Buy-in (the QMB or SLMB programs). Your change will not be effective until the first day of the following month, or
During a special enrollment period (you have extra help and were auto-enrolled into a plan, you move out of state, or other special circumstances)
Between November 15 - December 31st each year if you only have Medicare.
More information about exceptions and appeals:

Click here for a fax letter a pharmacist can use to send to a doctor when a prescription is denied by a Medicare Part D Plan

Click here for Medicare's guidelines regarding the exceptions and appeals process