A Medicare Part D exception is a request to have a non-formulary drug covered or to have a drug covered at a lower tier. You can request a formulary exception (cover a non-formulary drug) or a tiering exception (cover a drug at a lower tier). Your doctor must provide a statement of medical necessity.
Key Points
- Formulary exception: request to cover a non-formulary drug
- Tiering exception: request to cover a drug at a lower tier
- Doctor must provide statement of medical necessity
- Plan must respond within 72 hours (24 hours for urgent requests)
- An independent agent can help you navigate the exception process