Orlando Harmon
If you're enrolled in a health insurance plan, your doctor may sometimes prescribe medication that is not covered by your plan. In this case, you can request an exception for your prescription. An exception request is a type of coverage determination where an enrollee, their prescriber, or their representative requests a tiering or formulary exception. A tiering exception should be requested to obtain a non-preferred drug at a lower cost, while a formulary exception should be requested to obtain a drug that is not included in the plan. The specific steps to apply for an insurance exception may vary depending on your insurance company and location, but generally, your doctor must confirm that the drug is appropriate for your medical condition.
| Characteristics | Values |
|---|---|
| Who can request an exception? | An enrollee, an enrollee's prescriber, or an enrollee's representative |
| Types of exceptions | Tiering exception, formulary exception |
| Tiering exception | Requested to obtain a non-preferred drug at the lower cost-sharing terms applicable to drugs in a preferred tier |
| Formulary exception | 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 |
| Who can confirm the necessity of the exception? | The doctor or prescriber must confirm to the health plan that the drug is appropriate for the patient's medical condition |
| How to confirm the necessity of the exception? | Orally or in writing |
| What to do if the exception request is denied? | Appeal the decision or look for alternative medications |
| What if the appeal is denied? | Request a review by an independent review organization |
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What You'll Learn
- Requesting a tier exception to obtain a non-preferred drug at a lower cost
- Requesting a brand exception to cover a brand-name drug
- Appealing a denial and requesting a review by an independent organisation
- Requesting a formulary exception for a drug not included on a plan sponsor's formulary
- Getting a prescription drug covered by a state-regulated health plan
Requesting a tier exception to obtain a non-preferred drug at a lower cost
Requesting a tier exception is a way to obtain a non-preferred drug at a lower cost. This process is typically initiated when an individual's health insurance plan covers their prescribed medication but the copayment is expensive. This could be because the medication is on a high tier, and higher tiers are associated with higher copayment costs.
To request a tier exception, you must demonstrate that the drugs on lower tiers are either ineffective or harmful to you. This is done by submitting a request for a tiering exception, which is a type of coverage determination. This request can be made by the enrollee, the enrollee's prescriber, or the enrollee's representative. It should include a letter of support from your prescribing physician, explaining why similar drugs on the plan's formulary at lower tiers are inappropriate for you. This letter can be submitted verbally or in writing, and if done verbally, a written follow-up may be required.
The request should be submitted to the plan sponsor, who will make a decision within 72 hours of receiving the request. If the request is urgent, a decision should be made within 24 hours. If the request is denied, the enrollee can appeal the decision and have it reviewed by an independent third party, or discuss alternative medications with their healthcare team.
It is important to note that the details of every plan's exceptions process may vary, so it is recommended to contact your insurance company for specific information regarding their process.
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Requesting a brand exception to cover a brand-name drug
If your insurance plan does not cover a brand-name drug, you may be able to request a brand exception to get it covered. This is a type of coverage determination that can be requested by an enrollee, an enrollee's prescriber, or an enrollee's representative.
To request a brand exception, you or your healthcare provider must submit a written request to your insurer. This request should include medical documentation demonstrating the necessity of the brand-name drug. Insurers often require a standardized form outlining the physician's rationale, past treatment failures, and supporting clinical evidence. Some insurers may also require confirmation that no covered alternative is medically appropriate.
When submitting a request for a brand exception, it is important to provide clear evidence justifying why the brand-name drug is necessary when lower-cost alternatives are available. Medical necessity is typically the key factor in approving a brand exception. This can include situations where the patient's condition cannot be managed with generic or preferred alternatives due to treatment failures, adverse reactions, or unique medical circumstances.
To strengthen the request, it is helpful to include supporting documents such as progress notes, diagnostic test results, or records of adverse reactions. Referencing peer-reviewed studies, clinical guidelines, or FDA prescribing information can also bolster the argument for a brand exception.
It is worth noting that the exceptions process may vary depending on your insurance company. Therefore, it is recommended to contact your insurance provider for specific information on their process and requirements. Additionally, your healthcare team can help you file exception requests and provide the necessary evidence and supporting paperwork.
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Appealing a denial and requesting a review by an independent organisation
If your health insurance company denies your claim for prescription medication, you have the right to appeal the decision and request a review by an independent third party. This process may be called an "external review" and involves the following steps:
- Understand the reason for denial: Before starting the formal appeal process, it is important to understand why your claim was denied. Common reasons for denial include prior authorization requirements, step therapy requirements, quantity limits, or the drug being non-formulary (not on the plan's list of covered drugs).
- Contact your insurance company: Different insurance companies may have varying internal appeals processes, so it is important to contact them or refer to your denial letter for specific instructions. There may be time frames and deadlines associated with filing an internal appeal, so act promptly.
- Gather supporting documentation: Work closely with your healthcare team to gather evidence and supporting paperwork. This may include a letter of support from your healthcare provider explaining why the prescribed medication is medically necessary for you. Ensure that you include all the information requested by the insurance company, such as the member's name, identification number, dates of service, and specific reasons for appealing.
- File an internal appeal: Submit your appeal to the insurance company, requesting them to reconsider their decision. They are obligated to provide a full and fair review of their initial decision. If your case is urgent, you can request an expedited internal review, and they must speed up the process.
- Proceed with an external review: If your internal appeal is denied, you can request an external appeal to an independent review organization (IRO) or Independent Review Entity (IRE). This step involves having your appeal reviewed by a third party, and the insurance company no longer holds the final decision-making power. For Medicare Part D denials, you typically have 60 days from the date of the plan denial to submit your appeal to the IRE.
Remember that the appeals process may vary depending on your insurance company and the specific circumstances of your case. It is important to carefully follow the instructions provided by your insurance company and seek assistance from your healthcare team as needed.
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Requesting a formulary exception for a drug not included on a plan sponsor's formulary
A formulary exception is a request to your insurance plan to cover a medication that is not included in the plan's drug list or formulary. This can also be used to waive a utilization management requirement, such as step therapy, prior authorization, or a quantity limit for a formulary drug. Formulary exceptions are typically granted when a plan sponsor deems that a requested drug is medically necessary for an enrollee.
To request a formulary exception for a drug not included on a plan sponsor's formulary, the enrollee's prescriber must submit a supporting statement to the plan sponsor. This statement can be submitted verbally or in writing. If submitted verbally, the plan sponsor may require the prescriber to follow up in writing. The prescriber's statement must indicate that the non-formulary drug is necessary for treating the enrollee's condition because all covered Part D drugs on any tier would be ineffective or have adverse effects, or that the number of doses under a dose restriction has been or is likely to be ineffective.
It is important to note that the details of every plan's exceptions process are different, so enrollees should contact their insurance company for specific information. During the exceptions process, the health plan may provide access to the requested drug until a decision is made. The plan sponsor must provide notice of its decision within 14 calendar days of receiving the request. If the decision is unfavorable, it will contain the information needed to file a request for redetermination.
If your health insurance company denies your exception request, you can speak with your healthcare team about appealing the decision or exploring alternative medications. Your healthcare team can help you file exception requests and provide supporting paperwork to explain why the prescribed medication is necessary.
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Getting a prescription drug covered by a state-regulated health plan
If you are enrolled in a state-regulated health plan, you can request an exception to get a prescription drug covered. This process overrides certain policies health plans may use to limit drug coverage, such as prior authorization, step therapy, or "fail first" protocols. You can request an exception for a non-preferred prescription drug or a drug your provider prescribed as "off-label".
Once you or your provider make a request to your insurer, they must respond within three days unless they need more information. If the request is urgent, they must respond within one day. If you do not hear back within the specified time, the request is automatically approved. If your health plan is stable, your insurer must allow you to remain on that drug while you wait for a decision on your exception request.
To get your drug covered through the exceptions process, your doctor must confirm to your health plan (orally or in writing) that the drug is appropriate for your medical condition. This could be based on the following reasons:
- All other drugs covered by the plan haven’t been or won’t be as effective as the requested drug.
- Any alternative drug covered by your plan has caused or is likely to cause harmful side effects.
- There is a limit on the number of doses you’re allowed, and the allowed dosage hasn’t worked for your condition.
- The drug likely won’t work for you based on your physical or mental makeup.
If your exception request is denied, you can speak with your health care team about appealing the decision or look for alternative medications. You have the right to appeal the decision and have it reviewed by an independent third party. If your appeal is successful, your insurer must retroactively cover the non-formulary drug and continue coverage for the duration of the prescription.
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Frequently asked questions
An insurance exception for prescription is when your health insurance company makes an exception to their process and covers a medication that is not normally covered.
An enrollee, an enrollee's prescriber, or an enrollee's representative can request an insurance exception for prescription.
You can request an insurance exception for prescription if your doctor believes that the medication is medically necessary for your treatment and there is no suitable less expensive alternative.
You can request an insurance exception for prescription by contacting your insurance company and providing evidence and supporting paperwork from your healthcare team explaining why you need the medication.
If your request for an insurance exception for prescription is denied, you can appeal the decision directly with your health insurer or request a review by an independent third party.
