Every Medicare Part D plan offers an “Exceptions” process where 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 list of covered drugs. Exceptions can also be used to get a plan to put a drug in a different co-payment tier, provide a different dosage, or provide a drug without pre-authorization. While exceptions may be requested by the enrollee, their appointed representative, or their physician, a supportive statement from the physician is required.
When a prescription is not covered by your Medicare Part D plan, the first thing you should do is call your physician and tell your doctor why your prescription was not covered. You or your physician may then call the plan and request an exception. Once an exception is requested, the physician must provide information to the plan detailing why this particular drug is needed by the enrollee. Decisions must be made within 72 hours of the request, but the physician can also request a more quick decision if it is medically necessary.
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