What needs to be done if a medically necessary drug is not on a plans formulary or requires prior authorization? Is there an exception or appeal process?
The prescriber always has a choice to change the prescription to another medically appropriate medication that is covered by the PDP. However, drug plans must provide an exception/appeal process for drugs not on their formulary. To file an exception or appeal, contact the enrollee’s plan. If a beneficiary has a prescription for a drug that requires prior authorization, the plan must also be contacted.
Related Questions
- What needs to be done if a medically necessary drug is not on a plans formulary or requires prior authorization? Is there an exception or appeal process?
- The drug my doctor prescribed requires precertification, step-therapy or has quantity limits. How can I get an exception if necessary?
- What if I pay cash and submit a receipt for reimbursement for a drug that requires medical exception or a prior authorization?
