Formulary Exceptions: What to Do If Your Medication Isn’t Covered

HeyMOE Tip:
If you ever get a “Not Covered” message for a drug in your results, check with your doctor to see whether a Formulary Exception might be an option. Sometimes, it’s as simple as your physician confirming why no other alternative works for you — and that statement can make all the difference.

If you need a medication that your Medicare Part D plan doesn’t cover, don’t panic — your doctor can request what’s called a Formulary Exception on your behalf.

A formulary is simply your plan’s list of covered drugs. Each plan decides which medications it includes, which ones need prior authorization, and which have quantity or step-therapy limits.

When you and your doctor run into a coverage problem mid-year, a Formulary Exception can help in two main ways:

• Request coverage for a drug that’s not on your plan’s formulary, or

• Request an exception to a restriction (like prior authorization, step therapy, or quantity limits).

What Your Doctor Needs to Do

Your prescribing doctor must send a supporting statement to your plan explaining why the exception is medically necessary.

That usually means explaining that:

• No covered drug will work as well for you, and/or

• The covered drugs would cause harmful side effects.

Your plan can’t process the request without this documentation — so it’s critical that your physician completes it fully.

What Happens Next

Once your plan receives the request:

1. They typically respond within 72 hours (or 24 hours if it’s an emergency).

2. If approved, you’ll get access to the requested medication at your normal plan copay level for the tier of the medication assigned.

3. If denied, don’t give up — you have the right to appeal the decision.

How to Appeal a Denial

If your plan denies your exception request, you (or your doctor) can start an appeal. There are multiple levels of appeal, each with clear timelines and rules.

Here are two reliable resources that explain the steps:

• Medicare Prescription Drug Coverage Appeals
• Coverage Exceptions — Centers for Medicare & Medicaid Services (CMS)