Medical Exception Forms: How to Get Started
Filling out a medical exception form is an essential step for ensuring that you receive the care and medications you need, especially if there have been changes to your insurance coverage. Whether you’re dealing with a new insurance plan or facing a disruption in your current coverage, it’s crucial to approach this process with clarity, organization, and effective communication. In this post, we’ll walk you through how to fill out a medical exception form, with a special emphasis on the importance of staying in touch with both your insurer and healthcare team.
What is a medical exception form?
A medical exception form typically requests accommodations or exceptions for specific medical reasons. Common reasons someone might need to fill out a medical exception form include access to specialized care or treatments (e.g., coverage for a specific treatment under an insurance policy).
1. Identify if Your Insurance Plan Has Changed
The first step is to check if there has been a change in your insurance plan. Insurance companies often update their plans, coverage, and formulary (the list of covered medications), and these changes can impact your ability to access certain treatments.
Action Steps:
- Call Your Insurer: Contact your insurance company to ask if there have been any changes to your policy that could affect your coverage. This is particularly important if you’re on a specialized medication or treatment regimen, such as Adempas for pulmonary hypertension or other complex conditions.
This step is critical because it helps you understand whether or not you’ll need to request a medical exception to continue receiving your prescribed treatment. If your plan has changed, your insurer may have different procedures for requesting coverage exceptions, so it’s essential to get as much detail as possible during this call.
2. Call Your Care Team
Once you’ve confirmed that your insurance plan no longer covers your medication, or if you’re unsure about the next steps, it’s time to get in touch with your healthcare provider. Effective communication with your care team is the next key step in the process. Your doctor or specialist will be your advocate in helping to complete the medical exception form and ensure your treatment continues without interruption.
Action Steps:
- Call Your Doctor’s Office or Care Team: Notify them immediately that your insurance plan is no longer covering your medication or treatment. Be prepared to provide the following information:
- Details about the change in your insurance coverage.
- The medication or treatment that is no longer covered (e.g., Adempas).
- Any documentation or communication you received from your insurer.
- Request Assistance with the Medical Exception Form: Ask your doctor or care team to initiate the process of filling out the medical exception form. Your healthcare provider will typically need to:
- Complete the form: The medical exception form usually requires your doctor to explain why the prescribed medication or treatment is medically necessary for your condition.
- Provide supporting documentation: This could include medical records, test results, or a letter from your healthcare provider outlining the importance of your treatment and why an exception to the insurance policy is needed.
- Submit the form to the insurer: In some cases, your healthcare provider may submit the form directly to the insurance company. Other times, they may need you to submit it.
Why Communication Matters in This Step
When dealing with a medical exception request, clear and prompt communication between you, your insurer, and your healthcare team is critical. The more effectively you communicate, the smoother the process will be.
- With Your Insurer: By calling your insurance company first, you gather all the necessary information about changes to your plan, your options for continuing treatment, and the necessary steps for requesting an exception. It’s essential to keep a record of who you spoke to and what was discussed during these calls.
- With Your Healthcare Provider: Your doctor or care team’s involvement is crucial. They are the ones who can justify the medical need for your medication and help ensure your insurer understands the necessity of the treatment. By calling them right away, you give them time to handle the form, fill it out accurately, and make sure everything is in place to avoid delays.
Tips for Effective Communication:
- Be Clear and Concise: Whether you’re talking to your insurer or your care team, be specific about what changed with your insurance and why you need help.
- Ask Questions: Don’t be afraid to ask for clarification if you don’t understand something your insurer or care team says.
- Follow Up: After your initial contact, follow up regularly to make sure your request is being processed. Ask about the timeline for a decision, and check if any additional information is needed.
- Keep Copies of Everything: Throughout this process, be sure to keep copies of all forms, communications, and supporting documents. This will be invaluable if there are any complications or questions later on. Having a well-organized record of everything can also be helpful if you need to escalate your case or appeal any decisions.
3. Submit the Form and Follow Up
Once your healthcare provider has completed the medical exception form, be sure to ask both your insurer and care team questions on how and where to submit the form. This process could vary by case, so it is important to ask these clarifying questions for your specific situation.
After submission, it’s important to follow up regularly to track the progress of your request. For any issues or additional information needed, stay in touch with both your insurance and care team.
Remember: You’re advocating for your health and well-being, so be clear, detailed, and thorough in your request!
