How Does Someone Get Coverage for a Non Formulary Drug?

A fellow caregiver asked...

How does someone get Medicare prescription coverage for a non formulary drug?

Expert Answer

If you have a prescription for a drug that isn't on your plan's formulary, there are several things you -- or a family member -- can do. First, ask your Part D plan for an exception, which -- if granted -- would mean that the plan will cover the drug. To get this exception, your doctor needs to write to the plan stating that the nonformulary drug is medically necessary for you and that other drugs that are on the formulary would not be as effective or are more likely to have adverse effects. Each Part D plan has a specific procedure for making such a request. Your doctor's office can probably handle the process. If the doctor's office has not dealt with this particular Part D plan before, you can speed the process by requesting the proper forms from your plan and providing them to the doctor's office.

If the Part D plan refuses to grant the exception, it must explain why, in writing, to you. This is called a coverage determination and comes in the form of a "Notice of Denial of Medicare Prescription Drug Coverage." You have the right to appeal this decision; the procedure for appealing is explained in the notice of denial.

If you choose not to appeal, or the appeal is denied, there are still several options for obtaining an appropriate medicine without having to pay the full retail cost of the nonformulary drug. These are explained in Saving Money on Prescription Drugs When Not Covered by a Medicare Part D Plan.