What Can You Do If You’re Denied Coverage for a Drug? Understanding Medicare Part D Appeals

What Can You Do If You’re Denied Coverage for a Drug? Understanding Medicare Part D Appeals

What can you do if your Part D prescription drug plan will not cover a drug that you need? Below are three important points for exercising your Part D appeal rights.

 

Point 1: Know what an appeal is, and understand your right to file an appeal.

An appeal is a formal request for review of certain decisions to limit or deny coverage made by your Original Medicare, Medicare Advantage, or Part D plan. If you were denied coverage for a drug by your Part D plan, you may appeal the decision. Before you start your appeal, make sure you fully read all the letters and notices sent by your plan. Your doctor can appeal for you or can assist you by writing a letter supporting your appeal, but is not required to do so. There is more than one level of appeal, and if you meet certain conditions, you have the right to continue appealing if you are not successful at the first level. Be aware that at each level there is a separate timeframe for when you must file the appeal and when you will receive a decision. Make sure to file each appeal in a timely manner. If there is a reason you cannot submit your appeal within the timeframe, you may be eligible for a good cause extension. Remember that there is a difference between an appeal and a grievance. If you have a problem with your Part D plan that is not a formal request for them to cover a drug (like if your plan has poor customer service or you face administrative problems), you should contact your plan to ask about how to file a grievance.

 

Point 2: Know what to do if you are denied coverage for your drug at the pharmacy.

If your pharmacist tells you that your plan will not pay for your prescription drug, they should give you a notice titled Medicare Prescription Drug Coverage and Your Rights. Call your plan to find out the reason it is not covering your drug. Once you know why your drug was not covered at the pharmacy, speak to your doctor about your options. You may be able to try another drug that is on your plan’s formulary (their list of covered drugs).  If switching to another drug is not an option, you can choose to appeal. First, you will need to file an exception request (a formal coverage request) with your plan. Contact your plan to learn how to file an exception request. You will need a doctor’s letter of support for your exception request. If your exception request is approved, your drug will be covered. If your exception request is denied, your plan will send you a Notice of Denial of Medicare Prescription Drug Coverage.

 

Point 3: Understand how to appeal your Notice of Denial of Medicare Prescription Drug Coverage.

You have 60 days from the date listed on this notice to begin the formal appeal process by filing an appeal with your plan. Follow the directions on the notice. If a doctor is not appealing on your behalf, you should ask them to write a letter of support addressing the plan’s reasons for not covering the needed drug. If your plan approves your appeal, your drug will be covered. If your appeal is denied, you can choose to move to the next level of appeal. There are four levels of appeal after this initial step. At each level, if you are denied, follow the instructions on the denial notice to submit your next appeal. Follow all deadlines carefully. If your appeal is approved at any point, your Part D plan should cover your drug until the end of the calendar year.

 

Be sure to ask your plan if they will continue to cover the drug after the year ends. If they will not, you can appeal again next year, or consider switching Part D plans during Medicare’s Open Enrollment Period to a plan that does cover your drug.

 

Action Steps Summary:

  1. If you are denied coverage at the pharmacy, call your plan to find out why the drug isn’t being covered.
  2. Speak with your doctor about other options, and about filing an appeal.
  3. Contact your local Health Insurance Counseling and Advocacy Program (HICAP) for assistance with all the steps in the appeals process.
  4. Contact your California Senior Medicare Patrol (SMP) at 1-855-613-7080 if you suspect billing errors or think you have been the victim of fraud or attempted fraud.
  5. See our Part D Appeals section for more information.

 

This article is slightly edited from the Medicare Minute publication, by Medicare Rights Center, the SHIP National Technical Assistance Center, and the SMP National Resource Center.

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.