Don’t Forget the Formulary (Exception)!

by | Jan 26, 2022 | Blog, Medicare

For reprint by the GWAAR Legal Services Team

Although resources like the Medicare Plan Finder and the Marketplace Plan Comparison tool can help ensure that consumers get connected to insurance plans that cover their prescription drug needs, there are times when unexpected formulary issues can arise. Drug plan formularies can change from year to year. A prescription that was covered in the past may be subject to changes in price tiering or dose limitations in a new plan year and, in some cases, may no longer be covered at all. When these problems occur, requesting formulary exception may be a good solution.

In general, all commercial health insurance plans are required to have a procedure for requesting a formulary exception. When it comes to Part D prescription drug plans, the exception procedure offers additional flexibility. Part D plans are required to offer two different types of exceptions – a formulary exception and a tiering exception. The formulary exception allows a plan participant to request coverage of a drug that is not normally included in the plan formulary. A tiering exception allows the participant to request coverage of a non-preferred drug at the lower cost of a preferred drug.

Part D plans are required to allow participants to make formulary exception requests either verbally or in writing, though the plan may require a verbal request to be followed up by a formal written request. Either type of request must be submitted by the prescribing health care professional and both types of requests must include a supporting statement identifying why the preferred or excluded drug would not be as effective as the requested drug for treating the enrollee’s condition or how the preferred drug would have adverse effects for the enrollee. For a tiering exception, the request should additionally explain why the number of doses under a dose restriction have been or are likely to be less effective or why alternative drugs required to be used in accordance with step therapy have been or are likely to be less effective or have adverse effects.

When a formulary exception request is submitted, the drug plan must provide notice of its decision within 72 hours or within 24 hours for an expedited request. The initial decision may be provided verbally, but the plan must follow up with a written notice within three calendar days. As with any Medicare claim determination, the formulary request decision may be appealed through the usual redetermination, reconsideration, and administrative hearing procedures. Each Part D plan is likely to have its own proprietary form for making a formulary exception request, so plan participants will need to call the insurer or go to the plan’s website to access a copy of the appropriate form.

Connect with the ADRC Benefit Specialist team to learn more or for help requesting a formulary exception at (920) 448-4300.

Additional Information & Support

We are here to help you and your family with a wide variety of community resource options. For assistance by phone, or to make an appointment, contact us.

(920) 448-4300 | WI Relay 711

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