Pharmacies Must Notify Beneficiaries of Their Part D Appeal Rights ~ New Rule in Effect

Pharmacies Must Notify Beneficiaries of Their Part D Appeal Rights ~ New Rule in Effect

As of January 1st of this year, all beneficiaries who are denied coverage for a drug are entitled to receive a standardized written notice from the pharmacy explaining their Part D appeal rights.  This change is due to the Affordable Care Act (ACA). Prior to this year, pharmacies could either hand out this information or just post a notice in the pharmacy without specifically alerting an affected beneficiary to their appeal rights. In addition, prior to this year none of these appeals rights forms were standardized. The new rule from the ACA requires pharmacies to use a new standardized form, Medicare Prescription Drug Coverage and Your Rights (instructions and form can be downloaded here). A Spanish version will also be posted soon.

This requirement and standardized form is an important change for beneficiaries in terms of them being aware of and accessing their Part D appeal rights. Currently, the way the Part D appeals system is set up, the appeals process is NOT triggered when a beneficiary cannot obtain their drugs at a pharmacy. Nothing will happen unless the beneficiary proactively takes action and requests a “coverage determination” or “exception.” Only once an adverse coverage determination is initiated will the appeals process begin. (See our Part D appeals section for more info). Therefore, making sure each beneficiary who cannot get his/her drugs knows about their rights and HOW to start the appeals process is imperative to them having full access to their entitled benefits.

Questions regarding this new standardized notice can be sent to PartD_Appeals@cms.hhs.gov.

Additional information including frequently asked questions are included in the Centers for Medicare and Medicaid Services (CMS) memorandum sent out to all Part D sponsors entitled Revised Standardized Pharmacy Notice (CMS Form – 10147) (PDF).

Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.

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