What is an “exception” (Part D)?
If a drug is not covered in the way you would like it to be covered, you can ask the plan to make an “exception.” An “exception” is a type of coverage decision. Similar to other types of coverage decisions, if we turn down (deny) your request for an “exception,” you can appeal our decision.
When you ask for an “exception,” your doctor or other prescriber will need to explain the medical reasons why you need the “exception” to be approved. We will then consider your request. Here are three examples of “exceptions” that you, your doctor or other prescriber can ask us to make:
- Covering a Part D drug for you that is not on our List of Covered Drugs (Formulary).
- Asking us to waive coverage restrictions or limits on your drug. This can be Prior Authorization, Step Therapy, or Quantity Limit (limit the amount you can get at a time).
- Changing coverage of a drug to a lower cost-sharing tier. Every drug on the plan's Drug List is placed on a specific tier number. In general, the lower the cost-sharing tier number, the less you will pay as your share of the cost of the drug. This may vary depending on your plan. Check your List of Covered Drugs (Formulary) for details. You cannot ask to lower the tier if the drug is on a specialty tier (often tier 5) or not on the formulary.
Requesting an “expedited exception”
If you or your prescriber believe that waiting 72 hours for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 72 hours could seriously harm your health, we will automatically give you a decision within 24 hours. If you do not obtain your prescriber's support for an expedited request, we will decide if your case requires a fast decision. You cannot request an expedited coverage determination if you are asking us to pay you back for a drug you already received.
Important things to know about asking for “exceptions:”
Your doctor must tell us the medical reasons.
Your doctor or other prescriber must give us a written “exception” that explains the medical reasons for needing this drug.
- Covering a Part D drug for you that is not on our List of Covered Drugs (Formulary): This letter should explain why you cannot take any other drug on the formulary or are ineffective or harmful for you. Typically, our Drug List includes more than one drug for treating a particular condition. These different possibilities are called "alternative" drugs. If an alternative drug would be just as effective as the drug you are requesting and would not cause more side effects or other health problems, we will generally not approve your request for an “exception.”
- You can ask us to waive coverage restrictions or limits on your drug: This letter should explain why you cannot take any other drug on the formulary or are ineffective or harmful for you. This can include the drug that is part of the restriction called Prior Authorization or Step Therapy. If you are asking to waive the quantity limit, this letter should explain why the number of dose would not work for you.
- Changing coverage of a drug to a lower cost-sharing tier: This letter should explain why similar drugs on the plan’s formulary at lower tiers are ineffective or harmful for you.
For a faster decision, include this medical information from your doctor or other prescriber when you ask for the “exception”. If your doctor or prescriber does not include this information, it could take longer than the 24-72 hours.
You can ask for a coverage decision and/or “exception” by one of the following ways:
- Electronic Prior Authorization (ePA) at Cover My Meds Prior Authorization Portal
- Complete our online Request for Medicare Prescription Drug Coverage Determination form, which can be found on your plan's Pharmacy page.
- Fax: 1-866-388-1767
- Call Us: Refer to the Customer Service number on the back of your Member ID card.
- Write: Wellcare, Pharmacy-Coverage Determinations, P.O. Box 31397, Tampa, FL 33631-3397
- Overnight Address: Wellcare, Pharmacy-Coverage Determinations, 8735 Henderson Road, Ren. 4, Tampa, FL 33634
Learn more about coverage determinations and "exceptions" on the Centers for Medicaid & Medicare (CMS) website.