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DOCTOR IS CRUCIAL IN GETTING MEDICARE PART D TO COVER A DRUG THAT’S BEEN DENIED
One question advocacy groups frequently hear about the new Medicare prescription drug plan is “what if a drug I need isn’t on my plan’s list of covered drugs?” The answer lies in a special type of coverage decision called an “Exception”. Every Medicare Part D plan must offer this Exceptions process, through which enrollees can challenge the plans’ decisions.
Exceptions are a way to get Medicare Part D plans to reconsider such things as covering a drug that isn’t on their “formulary”, or list of covered drugs. Exceptions may also be requested to get a plan to put a drug in a different co-payment “tier”, provide a different dosage, formula or quantity, provide a drug without needing permission first, or provide a drug without needing to try another drug or drugs first. An Exception can also be requested for drugs that were on, but have been removed from, a Part D plan’s formulary. This may be important in the future, as Medicare Part D plans are allowed to change their formularies at any time with only 60 days’ notice, while those enrolled in a plan are locked into their plans for a year.
Exceptions may be requested by the enrollee, their appointed representative, or their physician. It is important to note that regardless of who requests the Exception, a supportive statement from the physician will be required.
When an enrollee is told by their pharmacy that a prescription will not be covered, the first thing he should do is call his physician to tell them the drug was not covered, and the reason given for the non-coverage. The physician, enrollee, or the enrollee’s representative may then call the plan and request an exception. Many plans will have forms for this purpose, but some will allow telephone requests. If an exception is requested by telephone, the request should also be followed by a written statement, and copies should always be kept.
Once an Exception is requested, the physician must provide information to the plan detailing why this particular drug is required by the enrollee. The required information may vary, depending on the reasons for the initial lack of coverage and the requirements of the plan.
Decisions must be made within 72 hours of the request. However, the physician may also request that a decision be made more quickly if he believes that going without a drug will harm the enrollee. The plan must then make a decision on the Exception within 24 hours.
An Exception must be granted by the plan whenever it determines that the drug in question is medically necessary, which is why the physician’s participation is so important to this process.
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