AHIP Practice Exam

What right does Mr. Zachow have regarding his Part D drug that is not on the formulary?

1. He can ignore the formulary requirements

2. He can request a formulary exception

3. He must switch to a different medication

4. He can appeal to the State for coverage

The correct answer is: He can request a formulary exception

Mr. Zachow has the right to request a formulary exception if his prescribed Part D drug is not listed on the plan's formulary. Medicare Part D plans are required to maintain a formulary which is a list of covered drugs. However, there are instances where a necessary medication may not be included. In such cases, beneficiaries can initiate a request for a formulary exception, which allows them to ask the plan for coverage of a drug that is not on the formulary based on medical necessity or other compelling reasons. This process involves the patient or their healthcare provider submitting a request to the insurance plan, often accompanied by supporting documentation explaining why the non-formulary medication is essential for the patient’s treatment. The Part D plan is then required to review this request and provide a decision based on the defined criteria, including clinical information and guidelines. This option reflects a fundamental aspect of patient rights within Medicare Part D that enables access to necessary medications even when they are not typically covered under the standard formulary.