Question

Mr. Zachow has a condition for which three drugs are available. He has tried two, but had an allergic reaction to them. Only the third drug works for him and it is not on his Part D plan's formulary. What could you tell him to do?

1) Mr. Zachow will have to wait until the Annual Election Period when he can switch Part D plans. In the meantime, he will have to pay for his drug out of pocket.
2) Mr. Zachow will need to enroll in a Special Needs Plan to obtain coverage for his medication.
3) Mr. Zachow could immediately disenroll from the Part D plan and select a new Part D plan that covers the drug that works for him.
4) Mr. Zachow has a right to request a formulary exception to obtain coverage for his Part D drug. He or his physician could obtain the standardized request form on the plan's website, fill it out, and submit it to his plan.

Answer 1

Mr. Zachow should request a formulary exception through his plan, which allows him or his physician to fill out a standardized request form from the plan's website and submit it for coverage of the medication that works for him.

Step-by-step explanation:

Mr. Zachow has encountered a common issue where his needs are not fully covered by his current Part D plan's formulary. Since he has had allergic reactions to the first two prescribed drugs and only the third one works for him, which is not covered by his plan, there are a few options he could consider. The most immediate solution is for him to request a formulary exception. Mr. Zachow or his physician can find the standardized request form on the plan's website, complete it, and submit it for coverage of the drug. While options such as waiting for the Annual Election Period to switch plans (option 1) or enrolling in a Special Needs Plan (option 2) are available, they may not provide immediate relief. The option to disenroll from the Part D plan and select a new one that covers the drug (option 3) may also pose timing and eligibility challenges.