Beginning in 2013, when your Part D plan will not pay for your drug, you should receive a notice at the pharmacy explaining your appeal rights titled Medicare Prescription Drug Coverage and Your Rights notice. It provides a general set options to potentially get your drug covered. Even though your plan will not pay for the medication, this paper is not a formal denial.
Call your plan to find out the reason for this refusal of coverage. If the refusal of payment is an error, it should be corrected. If it is not an error, you should refer to the top section of the notice, which lists the reasons your Part D plan may be refusing payment.
- You may have to get prior authorization or formally ask your Part D plan for coverage before it will pay.
- You may have to try step therapy or a different, less expensive drug first.
- Your drug may not be on your plan’s formulary or list of covered drugs.
- You may have a quantity limit, which is a restriction on the number of drugs you are allowed to take per month.
If the plan tells you your drug has been denied for one of these reasons, ask your doctor to write a letter of support to send to your plan requesting an exception to the plan’s rules. This letter should explain that another medication would be dangerous or less effective for you. You should get a decision from the plan within 72 hours. If you need your drug immediately because your health would be jeopardized by a long appeal process, your doctor can request an expedited appeal and you should get a decision from your plan within 24 hours.
If your plan approves your exception request, your drug should be covered for at least the rest of the year. If your exception request is denied, you should appeal.
For more information on the Medicare Prescription Drug Coverage and Your Rights notice, please call your plan, or 1-800-MEDICARE.