Reference Information for Answers
Question 1. The Social Security Administration's Program Operations Manual System provides detailed information about the low-income subsidy and the process of appealing adverse decisions about the subsidy.
Question 3. Section 423.578 (c)(3) - (4) of the MMA Regulations specifically address the length of an exception:
(3) When a tiering exceptions request is approved. Whenever an exceptions request made under § 423.578(a) is approved, the Part D plan sponsor must provide coverage for the approved prescription drug at the cost-sharing level that applies for preferred drugs, and may not require the enrollee to request approval for a refill, or a new prescription to continue using the Part D prescription drug after the refills for the initial prescription are exhausted, as long as— (i) The enrollee's prescribing physician continues to prescribe the drug; (ii) The drug continues to be considered safe for treating the enrollee's disease or medical condition; and (iii) The enrollment period has not expired. If an enrollee renews his or her membership after the plan year, the plan may choose to continue coverage into the subsequent plan year.
(4) When a non-formulary exceptions request is approved. Whenever an exceptions request made under § 423.578(b) is approved— (i) The Part D plan sponsor may not require the enrollee to request approval for a refill, or a new prescription to continue using the Part D prescription drug after the refills for the initial prescription are exhausted, as long as— (A) The enrollee's prescribing physician continues to prescribe the drug; (B) The drug continues to be considered safe for treating the enrollee's disease or medical condition; and (C) The enrollment period has not expired. If an enrollee renews his or her membership after the plan year, the plan may choose to continue coverage into the subsequent plan year.
Question 4. Section 423.578 (b)(3) of the MMA Regulations specifically addresses TrOOP and exceptions drugs:
(3) If the Part D plan sponsor covers a non-formulary drug, the cost(s) incurred by the enrollee for that drug are treated as being included for purposes of calculating and meeting the annual out-of-pocket threshold.
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