What if I need a drug that isn’t on the Medicare Formulary or costs too much?

If your physician determines that you need a drug that is not on a Part D plans formulary, they can ask the insurance company for an exception. However, there are rarely drugs that are not on the formulary that an insurance plan will grant an exception for. In most cases, these are experimental drugs that are not covered.

If you need a drug and it is too expensive, there are several ways you can get help with the cost.

  • Enroll in a Part D plan that offers additional coverage in the gap.
  • Consider switching to generics or other lower-cost drugs.
  • Apply for Extra Help, also known as low-income subsidy, which helps those with low income get help with prescription costs.
  • Many states have State Pharmaceutical Assistance Programs that help pay for prescriptions, Part D premiums, and/or other drug costs.
  • Pharmaceutical Assistance Programs. Some drug companies offer programs to help pay for medications for those enrolled in Part D plans. Ask your doctor or insurance company if there are plans available for the drugs you need help with.
  • There are also other national and community-based charitable programs to help with drug costs, including:

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