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How do I get a Medicare Prescription Exception?
A Medicare Part D Prescription Exception is a request made by a beneficiary or their prescribing doctor or provider for coverage of a medication that is not included on their Medicare Part D plan's formulary (list of covered drugs) or is subject to restrictions such as prior authorization, quantity limits, or step therapy requirements. In some cases, a Medicare Part D plan may approve a prescription exception and provide coverage for the medication, even if it's not typically covered by the plan. To request an exception, the beneficiary or their prescriber must submit a request to the Medicare Part D plan explaining why the medication is medically necessary and why alternative medications on the formulary are not appropriate or effective.
A type of Medicare coverage determination for prescription drugs is a formulary exception, which is a decision by a drug plan to cover a drug not on its drug list or to waive a coverage rule. A tiering exception is a decision by a drug plan to charge a lower price for a drug on its non-preferred drug tier. An exception must be requested by you or your prescriber, and your doctor or other prescriber must provide a supporting statement explaining the medical reason for the exception.
There are different types of Medicare Part D Prescription Exceptions, including:
1. Formulary Exception: Request for coverage of a drug that is not on the plan's formulary.
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2. Tier Exception: Request for coverage of a drug on a higher tier of the formulary at a lower copay or coinsurance rate.
3. Prior Authorization Exception: Request for coverage of a medication that requires prior authorization.
4. Quantity Limit Exception: Request for coverage of a medication that exceeds the plan's set quantity limits.
5. Step Therapy Exception: Request for coverage of a medication that is not the first choice for treating a medical condition but is necessary due to the beneficiary's inability to tolerate or respond to the preferred medication.
MedHelpCenter.us recommends that you call the Senior Health Insurance Agency at 813-592-8568 for further explanation.
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