What can a participant do if the prescribed drug isn’t covered by their drug plan?
The exception process permits access to drugs not on a Medicare prescription drug plan’s formulary or to reduce the cost-sharing of a drug under certain circumstances. Plans must grant exceptions regarding drugs not on the formulary when/if the plan determines that it is medically appropriate to do so. Plans must make their determination on an exception request as expeditiously as an enrollee’s health condition requires, but no later than 24 hours for an expedited decision involving enrollees who may suffer from serious health conditions, and 72 hours for a standard decision. If a plan denies an exception request, the enrollee, or his or her authorized representative (or, in expedited cases, the prescribing physician), may appeal the plan’s decision.
