You always have the right to make a formal request to ask your plan to cover a drug you need. This request is called asking for an exception. You will need a doctor’s help to do this, especially when a plan has placed restrictions on a drug you need.

You should always consider requesting an exception for a medically necessary drug in the following situations:

  • Your doctor prescribes a drug that is not on your plan’s formulary

Note: You cannot usually use the exception process if your prescription drug is excluded from Medicare coverage by law. However, you may be able to ask for an exception if you can show that your doctor prescribed your drug for a use that is not explicitly excluded. Explicitly excluded prescription drugs are those drugs that are never covered by Medicare.

  • Your plan replaces a brand-name drug you are taking with a generic version, and only the brand name will work for you.
  • Your plan drops a drug from its formulary during the year.
  • Your plan has restrictions on the drug you need, such as
    • Prior Authorization: You must ask your plan’s permission before it will pay for the drug.
    • Quantity Limits: Your plan will only cover a certain amount or dosage of a drug.
    • Step Therapy: Your doctor must show that you tried a less expensive medication before your plan will cover a more expensive one.
  • Your medication is in a higher “copay tier” than similar drugs on the formulary. If you are prescribed a “non-preferred,” more expensive drug because your doctor thinks it is the only medication on the formulary that will work for you (there is no good generic or “preferred” alternative), you can ask your plan to move your medication to a lower cost tier. Drugs on lower tiers of a formulary cost less.

However, you cannot request that your plan move the drug to a lower tier if

  • the drug you need is in a “specialty tier” (often the most expensive drugs); or
  • you want to access a brand-name drug at the same copay tier as a generic drug.

Note: Your plan does not take your income into account when you ask for a tiering exception.