MHI – Q: What happens if my doctor prescribes a drug not on my plan’s formulary?

A: You might want to ask your doctor to prescribe another medication if the one he or she prescribes is not on your drug plan’s formulary. If your doctor prefers not to prescribe a different medication, then you could submit a coverage exception to your plan.

The doctor must provide documentation to the plan showing why you need that particular medication. The plan will treat the coverage exception request as either a “standard” or an “expedited” request. The plan must respond to standard request within 72 hours. If there is a concern that your health would be compromised by waiting for 72 hours, your expedited request will be answered in 24 hours. If your initial request is denied, you may appeal.

Regardless of the decision, perform a drug plan comparison during the next Open Enrollment Period to select a plan for next year that does have the medication on their formulary.

Here’s a tip to head off this situation – always bring a copy of your formulary to every doctor’s appointment. If your doctor needs to prescribe a new medication, ask if he or she can prescribe a medication that is on your formulary. That way, you can afford to take whatever medication your doctor prescribes.