What is an Exception?
What is an Exception?
An exception is a type of coverage determination request. All Medicare drug plans have to have a timely and well-organized process for making coverage determination decisions, as well as decisions on exception requests.
The exception procedure is a quick, simple way to ensure people with Medicare can get the drugs they need. Through an exception, a member may be able to get a non-preferred drug at a better out-of-pocket cost, get a drug that isn't on the plan's formulary, or ask their plan not to apply a utilization management tool (for example, a prior authorization or step therapy requirement). When you or your doctor present evidence to the plan in support of an exception request, the plan must inform you of its decision no later than 72 hours from the time it receives the supporting information from your doctor or 24 hours from the time it receives the supporting information from your doctor if your case is "expedited" due to an urgent health condition. The most ordinary situations in which members may request an exception take in:
- The member is using a drug on their plan's formulary that is detached during the plan year for reasons except security and there is no other drug on the plan's formulary that the member can use;
- The member's doctor advises a medically essential drug that isn't on the plan's formulary;
- The member is using a drug that is moved, during the plan year, from the preferred to the non-preferred level and the member can't use any other drugs on the preferred level;
- The member's doctor prescribes a drug that is in the plan's more expensive cost-sharing level because he/she believes the drug(s) in the less expensive cost-sharing level is medically unsuitable for the member; or
- The member's doctor recommends a drug on the plan's formulary that is subject to a utilization management tool (for example, a prior authorization or step therapy requirement) that he/she believes the member can't meet.
Usually, plans must approve exceptions when they find that the drug is medically required, steady with the supporting information provided by the member's doctor.
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