AHIP Practice Exam

What action can Mr. Zachow take to obtain coverage for a non-formulary drug?

1. Submit a claim for reimbursement

2. Ask his employer for assistance

3. Request a formulary exception

4. Select a different plan for next year

The correct answer is: Request a formulary exception

To obtain coverage for a non-formulary drug, Mr. Zachow can request a formulary exception. This process involves formally asking the insurance provider to cover a medicine that is not included in the plan's list of approved drugs (the formulary). Requesting a formulary exception is a recognized procedure that allows patients to seek coverage for necessary medications when they cannot use the alternatives listed on the formulary due to medical reasons or other considerations. This option is especially relevant because insurance plans often have specific protocols for handling exceptions, and providing necessary documentation or a doctor's letter may strengthen the request. In contrast, submitting a claim for reimbursement typically pertains to expenses already incurred, not a proactive approach to obtaining coverage for a currently needed non-formulary drug. Asking the employer for assistance might not directly resolve the issue of coverage, as employers often do not have the authority to alter pharmacy benefit decisions. Selecting a different plan for the next year is not a viable immediate solution, as it would only apply to future medications, and might not address the need for coverage in the current plan period. Thus, requesting a formulary exception is the most direct and effective method for Mr. Zachow to seek the coverage he needs promptly.