If you’ve been prescribed a medicine that is not on your Part D plan’s formulary (list of covered drugs), you can ask that your plan to cover it by requesting an exception to the formulary. This is the first step in a coverage determination. Your doctor will need to explain in writing the medical reasons why you need to take this drug. If your plan denies coverage, you can then file an appeal for the plan to reconsider its decision.
Certain prescription medicines or treatments have rules that require that you to get approval or precertification from the plan before the plan will agree to cover the drug or treatment. In situations where your medication or treatment requires a prior authorization you will need to ask your doctor to contact the plan directly with the medical reasons why you need the medication or treatment covered. Make sure to check your plan’s formulary or summary of benefits to see if you need a prior authorization (PA) before you are treated or fill your prescription to avoid any delays.
A formulary is a list of covered drugs provided by a plan. Formularies may vary in from plan to plan and the list of covered drugs can change from year to year. It’s a good idea to find out if your medications are covered before you join a plan or want to switch plans during the Open Annual Enrollment Period. You can usually review enrollment materials like the formulary online, call Customer Service, or request a formulary be mailed to you.