What does formulary exception mean?
Table of Contents
What does formulary exception mean?
A formulary exception should be requested to obtain a Part D drug that is not included on a plan sponsor’s formulary, or to request to have a utilization management requirement waived (e.g., step therapy, prior authorization, quantity limit) for a formulary drug.
What is the medical exception process?
The Exception Request Process Exception requests are granted when a plan determines that a requested drug is medically necessary for that patient. Therefore, no matter who initiates the exception request, the prescriber must submit a statement supporting medical necessity.
What is formulary override?
request letter. A formulary exception is a type of coverage determination used when a drug is not included on a health plan’s formulary or is subject to a National Drug Code (NDC) block.
What medication does Medicare not cover?
Medicare does not cover:
- Drugs used to treat anorexia, weight loss, or weight gain.
- Fertility drugs.
- Drugs used for cosmetic purposes or hair growth.
- Drugs that are only for the relief of cold or cough symptoms.
- Drugs used to treat erectile dysfunction.
What is a formulary restriction?
A list of medica- tions (formulary) which limits access of a practitioner to some medications. A closed formulary may limit drugs to specific physicians, patient care areas, or disease states via formulary restrictions.
Who qualifies for medical exemption certificate?
Medical exemption certificates are credit-card-size cards. They are issued if you have: cancer, including the effects of cancer or the effects of current or previous cancer treatment.
What drugs does Part D cover?
What does Medicare Part D cover?
- Anticonvulsants, used to treat epilepsy and other conditions, including mental health conditions.
- Antidepressants.
- Antipsychotics.
- Immunosuppressant medications used to prevent organ transplant rejection.
- Antiretrovirals, used to treat HIV/AIDS.
- Antineoplastics, used to treat cancer.
