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Formulary (your list of covered drugs) Exceptions and Tier Exceptions

From CMS.gov

Exceptions requests are granted when a plan sponsor determines that a requested drug is medically necessary for an enrollee.  Therefore, an enrollee's prescriber must submit a supporting statement to the plan sponsor supporting the request.

  • For tiering exceptions, the prescriber's supporting statement must indicate that the preferred drug(s) would not be as effective as the requested drug for treating the enrollee's condition, the preferred drug(s) would have adverse effects for the enrollee, or both.
  • For formulary exceptions, the prescriber's supporting statement must indicate that the non-formulary drug is necessary for treating an enrollee's condition because all covered Part D drugs on any tier would not be as effective or would have adverse effects, the number of doses under a dose restriction has been or is likely to be less effective, or the alternative(s) listed on the formulary or required to be used in accordance with step therapy has(have) been or is(are) likely to be less effective or have adverse effects.
Medicare Drug Exception Form

Late Enrollment Penalty Issues

From CMS.gov

Medicare beneficiaries may incur a late enrollment penalty (LEP) if there is a continuous period of 63 days or more at any time after the end of the individual's Part D initial enrollment period during which the individual was eligible to enroll, but was not enrolled in a Medicare Part D plan and was not covered under any creditable prescription drug coverage.

A Medicare Part D plan notifies an enrollee in writing if the plan determines the enrollee has had a continuous period of 63 days or more without creditable prescription drug coverage at any time following his or her initial enrollment period for the Medicare prescription drug benefit. The enrollee will receive an LEP Reconsideration Notice and an LEP Reconsideration Request Form with the written notification. The enrollee or his or her representative may request a review, or reconsideration, of a decision to impose an LEP.  An enrollee may only obtain review under the circumstances listed on the LEP Reconsideration Request Form.

LEP Appeals Form

Medicare Part B Enrollment Form

From CMS.gov

WHO CAN USE THIS APPLICATION?

People with Medicare who have Part A but not Part B
NOTE: If you do not have Part A, do not complete this form. Contact Social Security if you want to apply for Medicare for the first time.

WHEN DO YOU USE THIS APPLICATION?

Use this form:

  • If you’re in your Initial Enrollment Period (IEP) and live in Puerto Rico. You must sign up for Part B using this form.
  • If you’re in your IEP and refused Part B or did not sign up when you applied for Medicare, but now want Part B.
  • If you want to sign up for Part B during the General Enrollment Period (GEP) from January 1 – March 31 each year.
  • If you refused Part B during your IEP because you had group health plan (GHP) coverage through your or your spouse’s current employment. You may sign up during your 8-month Special Enrollment Period (SEP).
  • If you have Medicare due to disability and refused Part B during your IEP because you had group health plan coverage through your, your spouse or family member’scurrent employment.
  • You may sign up during your 8-month SEP.

NOTE: Your IEP lasts for 7 months. It begins 3 months before your 65th birthday (or 25th month of disability) and ends 3 months after you reach 65 (or 3 months after the 25th month of disability).

Part B Enrollment Form