Medicare Part D: exceptions and appeals process.

Abstract

Once enrolled in a Medicare Part D prescription plan, the focus changes to access to medically necessary medications through the prescription plan. In many situations, this will involve the exceptions and appeals process. Each Medicare plan has its own drug formulary and differentiates itself through various parameters within those formularies. The federal government has rules in place for what may or may not be covered in a formulary, and has specified parameters for an exceptions and appeals process. It is the responsibility of the patient, along with his or her physician, to learn about and take advantage of mechanisms built into the system to ensure access to medically necessary medications. As physician reimbursement moves to an outcome-based through pay-for-performance system, physicians will have a financial incentive for assuring that their patients receive the necessary medications.