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How do nursing home residents get coverage for drugs that are not on their plan’s formulary?

2018-01-15T14:50:01+00:00

Nursing home residents have access to the same process to appeal drug coverage determinations as non-nursing home residents. At the same time, it can be exceptionally difficult for nursing home residents, particularly those with cognitive impairments, to go through the exceptions process to get coverage for non-formulary drugs without someone acting on their behalf to secure the required information from a physician and to file an appeal if necessary. This makes it especially important that family members or legal guardians help these enrollees go through the appeals process. Nursing homes are required under the 1987 Nursing Home Reform Law to provide the needed prescription drugs whether or not there is a payment source. This ensures a safety net is in place to protect those nursing home residents who are not successful in receiving coverage.