The Part D formulary is a list of drugs that have coverage under your policy. The formulary must include at least two drugs per category; however, the insurance company can choose the options.
Within the formulary, you’ll find tiers; these tiers are mostly generic and brand name categories. However, some carriers break it down further with tiers like preferred generic, generic, preferred brand, brand, and specialty tier drugs.
But what exactly is a drug formulary? What happens if your medication isn’t part of this formulary? We’re here to address all those questions, and so much more!
What is a Part D Formulary
Part D is your prescription drug coverage and is available through private insurance companies that Medicare approves.
All Part D plans should cover a minimum of at least two drugs in every drug class. However, Medicare doesn’t cover medications for weight loss or cosmetic purposes.
Further, over the counter drugs don’t have coverage either.
Does Every Drug Plan Have A Formulary
Every insurance plan has its drug formularies. Each medication must adhere to the Food and Drug Administration’s (FDA) regulations.
Medicare does regulate drug options for the six-protected classes; these include drugs for mental illness, cancer, HIV/AIDS, epilepsy, and patients going through organ transplantation.
Although, those with a grocery list of medications should contact an agent to determine the most suitable policy.
What is a Tiering Exception
A tiering exception is a request to lower your cost-sharing. To qualify for a tiering exception, the doctor must prove the preferred drug option wouldn’t be as effective as the prescription, or the document would show the preferred drug doesn’t work for you; in some cases, both.
Talking to your doctor is the best way to determine if a tiering exception is right for you.
What is a Formulary Exception
If the medication that you need is not on your Part D formulary, you seek a formulary exception. A Formulary Exception is a form of a request to determine coverage.
By obtaining an exception, you may be able to get a drug that’s not on your plan’s formulary or ask your plan to bypass step therapy or prior authorizations.
Step Therapy is a process in which you’ll try one drug to treat your condition first before receiving coverage for any other medicines for the same affliction.
There may be circumstances in which you’ll need to complete additional coverage requirements to prove that you can use your medications in the safest possible way.
In these situations, your insurance carrier may require you to obtain a Prior Authorization before they cover specific medications.
To get consent, you and your doctor will need to submit a Prior Authorization explaining the reasons behind your need for the drug in question.
How to Petition for A Part D Formulary Exception
To request a Formulary Exception, your physician will complete an Exception form on your behalf and submit it to your health insurance policy.
What Happens if an Exception Receives A Denial
If your prescription coverage determination isn’t acceptable, your decision will provide all the necessary information to submit a request for redetermination with your plan.
What Situations Would Warrant an Exception
Several common occurrences could warrant your request for a tiered or formulary exception. If these things occur, an exception could be in your future.
You may qualify for a formulary exception if:
- A doctor prescribes a medication that’s medically necessary but not on the plan’s formulary
- You’re using a drug that moves from the preferred to the non-preferred tier, and you’re unable to use other medications
- A doctor prescribes a prescription, but it requires prior authorization or step therapy; however, you don’t feel you can meet the requirements
- Your plan removes your medication from the formulary, and there aren’t other drugs you can use
Keep in mind, just because one of these is valid, it doesn’t mean you’re guaranteed a formulary exception.
When Is A Formulary Exception Likely to Be Approved
Exceptions are more likely to see an approval when the requested medication is medically necessary for you. Your doctor must submit a statement to your plan supporting the exception request.
If you’re seeking a tiering exception, your doctor’s report must state that the preferred medications would result in adverse effects.
If you’re trying to obtain a formulary exception, your doctor’s statement must indicate that the non-formulary drug is necessary.
The report must also note that other medications in different tiers would not be as effective or could cause severe adverse reactions.
What Happens If A Drug Is Not on The Formulary for Medicare Part D
If your doctor prescribes a medication that isn’t on your insurance plan’s drug list, you’ll be responsible for the entirety of the cost of the prescription rather than just a copayment.
However, if you qualify for a formulary exception, you may be able to avoid paying full price.
How often does Medicare update the formulary list
Each calendar year, Part D prescription policies may change deductible, copayments, premiums, and medications they cover.
Your Part D plan will send you an Annual Notice of Change every September, which will notify you of all changes you can expect to see in the upcoming new year.
If you should choose to switch Part D plans because of impending changes, you can do so during the
Annual Enrollment Period – October 15th through December 7th.
Part D may make changes to its drug formularies throughout the year. Some of these changes may include adding or dropping some coverage, depending on Medicare’s regulations.
There may be instances in which a change involves one of your medications.
Should you experience a change, your plan must provide written notice 30 days before the changes taking place.
When you refill, you must take notice of the changes in writing, and you can get a 30-day supply under the previous terms.
How to Determine Part D Formulary Eligibility
There are several ways to check eligible on your Part D drug formulary. Your doctor can help you in determining if the new medicines they’re prescribing you will fall under your plan’s formulary.
You can also have your pharmacist look into the medications that will fall under your plan’s formulary.
If you have a health insurance agent, they can assist in finding your plan’s formulary list. You can check insurance carrier websites to view the drug formularies they offer.
Prescription drug coverage can be an incredibly beneficial benefit to pairing along with your Part A and B coverage. If you’d like more information on Part D formularies, call our team of agents today!
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