The Medicare Part D formulary is a list of drugs that have coverage under your policy. The formulary must include at least two drugs per category, and the insurance company can choose the options.
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 the Medicare Part D Formulary?
The Medicare Part D Formulary is a list of covered drugs on your prescription drug plan. The plan can change the formulary anytime, but they must notify you. Each plan has a different list of drugs.
You’ll want to find the formulary that fits with the medications you take. But, it can be hard to predict next year’s prescriptions. So, what do you do when a new prescription isn’t on the formulary? We will get to that later, but first, let’s go over some important details.
Do all Drug Plans Have a Formulary?
Yes, all drug plans have a formulary. Plans will include generic and brand-name prescriptions.
Plans must cover the six protected classes. But, every formulary may not contain your medication.
Every insurance plan has its drug formularies. Each medication must adhere to the Food and Drug Administration’s (FDA) regulations.
Who Has the Best Part D Formulary?
Medicare Part D plans have a star-rating system similar to Medicare Advantage. Many locations don’t have 5-star plans, but some areas will have those options.
What Happens if a Drug is Not on the Formulary for a Medicare Part D Provider?
If your drug isn’t on the formulary, you’ll likely pay the full price. Of course, you can request a formulary exception or file an appeal.
How Can I Appeal a Drug on the Part D Formulary?
You can file an appeal when you disagree with the decision made by the insurance company. So, if the plan denies a drug claim but you believe it should have coverage, you can file an appeal. You may need supporting documents to show necessity, prior authorization, or step therapy requirements have been met.
How Can I Get a Drug on the Part D Formulary?
If the medication 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.
To request a Formulary Exception, your physician will complete an Exception form on your behalf and submit it to your health insurance 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.
How to Petition for a Part D Formulary Exception?
If your prescription coverage determination isn’t acceptable, your decision will provide all the necessary information to submit a redetermination request 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 doesn’t mean you’re guaranteed a formulary exception.
When Is A Formulary Exception Likely to Be Approved?
Exceptions are more likely to see 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 adversely affect you. 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.
How to Know What Medications are in a Medicare Part D 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.
Those with Medicare are eligible for a drug plan and should enroll as soon as possible. If you’d like more information on Part D formularies, call our team of agents today!
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