- Medicare drug exceptions are typically made in situations where an individual has a medical need for a prescription drug that is not covered by the individual’s PDP, but where the drug is deemed medically necessary by the individual’s healthcare provider.
- To request a Medicare drug exception, a beneficiary will need to submit a written request to their PDP explaining their medical need for the drug and providing supporting documentation from their healthcare provider. The beneficiary’s PDP will review their request and decide about whether to grant the exception. If the request is granted, the beneficiary’s PDP may provide coverage for the drug either through a coverage determination or through
a formulary exception. - It is important to note that Medicare drug exceptions are not guaranteed, and a request may be denied if it is not deemed medically necessary or if it does not meet other Medicare coverage criteria. If a request for a Medicare drug exception is denied, the beneficiary may have the option to appeal the decision.
