Guide to Medicare Part D: Requesting an Exception

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This page is part of our Guide to Medicare Part D.

Contact your Part D plan to request an Exception.

Your request for an Exception must be in writing, UNLESS your health is in serious jeopardy.

Learn about Expedited Exceptions below. To be successful, your request for an exception needs to include written statements from your doctor that the drug is medically necessary and that there are not reasonable alternative medical therapies available.

You have the RIGHT to request an Exception when:
  • Your drug is not listed on your Part D plan's formulary, or
  • Your doctor fails to obtain prior authorization from your Part D plan to prescribe the drug to you, or
  • Your doctor prescribes a dosage that is not covered by your Part D plan, or
  • Your doctor prescribes a form (liquid versus pill), or type (generic versus brand) of drug that is not covered by your Part D plan, or
  • When your Part D plan removes your drug from its formulary, or
  • When you cannot afford the co-payment for your drug and your Part D plan offers other drugs at a lower price

If you need assistance requesting an Exception, you can ask your prescribing doctor or someone you trust to request an Exception for you.

NOTE: If someone other than your prescribing doctor is going to request an Exception for you, you will need to submit a written statement to your Part D plan authorizing someone to act for you.

You can get the standard Authorization form from the Medicare website.

IMPORTANT: To request an Exception, your prescribing doctor MUST contact your Part D plan and state why your drug is medically necessary.

What happens next?

Your Part D plan must contact you within 72 hours after it receives your doctor's statement to explain its decision.

What if I can't wait 72 hours?

You can request an Expedited Exception.

If you or your doctor believes that waiting 72 hours might seriously jeopardize your health, life, or ability to regain maximum function, you or your doctor can call your Part D plan and request an Expedited Exception.

Your Part D plan will decide if you qualify for an Expedited Exception depending on the seriousness of your health condition.

NOTE: Your Part D plan MUST grant a request for an Expedited Exception if your doctor personally calls your Part D plan and states that waiting 72 hours for a decision might seriously jeopardize your health, life, or ability to regain maximum function.

If your Part D plan grants the request for an Expedited Exception, it must contact you within 24 hours after it receives your doctor's statement to explain its decision.

What if the Exception decision is unfavorable?

Contact your doctor to discuss the decision. If your doctor believes the decision is incorrect, you can request an Appeal.

NOTE:You have the RIGHT to request an Appeal.

For questions or advice, contact
your nearest Kentucky legal services program.

Your Part D plan's written Exception decision will explain how to request an Appeal.

We have more information about the Appeal process.



Reviewed August 2009

This online guide was adapted with permission from Maine Legal Services for the Elderly. We extend our thanks to them.