People on Medicare may choose drugs that are not on the formulary list of their prescription drug plans. However, they may have to pay full price for those medications.
Although everyone who has Medicare is eligible for prescription drug coverage, this coverage is not provided directly by Medicare, but by many different insurance companies. All Medicare prescription drug plans must be approved by Medicare. People with Medicare can obtain prescription drug coverage by signing up for a Medicare Part D plan, which covers prescription drugs only, or a Medicare Part C plan, which is usually an HMO or PPO plan that includes prescription drug coverage.
Medicare does not have its own formulary list; each individual plan has its own formulary list. A patient with a Medicare prescription drug plan can request an exception if the patient or the patient's health care provider thinks that the patient needs a drug that is not included on the formulary list for the plan.
If the patient's insurance company denies the exception, the patient can appeal. There is a five-level appeals process available to the patient if the request is denied. Some steps of the appeals process can be expedited if a lengthy wait for a decision could cause serious medical consequences for the patient.