What to do if your drug plan denies your exception request: steps to filing an appeal
Question 4 of 5 (use "Last" or "Next" buttons to see more)
Last Update: June 19, 2012
If you have formally asked your plan to pay for a drug, override a restriction, or move your drug to a lower cost tier (requested an exception), and your plan turns you down, you should appeal.
Before you can begin the appeals process, you must have already asked for an exception and been officially denied in writing. A “no” at the pharmacy is not an official denial.
The process for appealing is the same whether you are in a Medicare private health plan with drug coverage (MA-PD) or stand-alone private drug plan (PDP).
How to appeal your plan's decision
- Your plan should send you a written denial titled Notice of Denial of Medicare Prescription Drug Coverage. The notice should clearly explain why the plan is denying coverage for your prescription and tell you where to send your appeal.
- You have 60 days from the date on the "Notice of Denial" to submit your appeal. (Under certain circumstances, you may be able to appeal after 60 days if you have good cause—for example, if you were in the hospital and therefore could not appeal earlier.) By appealing, you are asking for a redetermination from the plan.
- The plan must respond no later than seven calendar days from the date it received the request. If it is an emergency, you or your doctor can ask for an expedited redetermination. Your plan must respond to an expedited appeal within 72 clock hours.
- If you have to pay for your drug out of pocket since your plan denied your exception request, be sure to submit receipts and request reimbursement from your plan in your appeal.
If your plan reverses its own denial of coverage, the plan must authorize coverage no later than seven calendar days from the date it receives your appeal request (72 hours for an expedited appeal). If the case involves a reimbursement request, the plan must authorize reimbursement within seven days and pay within 30 calendar days from the date it receives your appeal request. Note: If your plan does not authorize coverage or provide reimbursement within these timeframes, file a complaint with your plan and notify the Independent Review Entity (IRE), Maximus Federal Services.
A signed Appointment of Representative form allows your doctor to represent you throughout the appeals process. A signed form also allows your doctor to represent you in any other Medicare prescription drug appeals over the course of the calendar year. Do not give up if your plan denies your appeal—have the Independent Review Entity (IRE) review your case. Maximus Federal Services is currently the private contractor that handles medicare prescription drug appeals when your plan has denied your request for coverage. Maximus is independent and is not affiliated with any Medicare private drug plan.
Appealing to Maximus is no more difficult or complicated than appealing to your plan. Appeal within 60 days of the date on the second Notice of Denial from your Medicare private drug plan. You or your doctor should simply send all of your documents, including any receipts for out-of-pocket expenses for the denied prescription, to Maximus. If your plan raised new reasons for denying coverage for your prescription in its second denial notice, your doctor may want to update his letter of medical necessity to address those new reasons. Send documents to Maximus Federal Services, 3750 Monroe Ave, Suite 703, Pittsford, NY 14534. Tel. 877-456-5302. Fax 866-825-9507. Maximus must return a decision within seven days for standard appeals and 72 hours for expedited appeals.
If your doctor submits this appeal on your behalf, you will need to appoint your doctor as your representative by signing an Appointment of Representative form. Have your physician submit the form along with the letter of medical necessity.
If you disagree with Maximus's decision, you can request an ALJ hearing within 60 days of Maximus's decision if the amount in question meets the minimum amount that Medicare sets each year ($140 in 2013). Multiple appeals can be consolidated to meet this amount, allowing you to project the cost of the drug to include all refills you will need for the calendar year. If you disagree with the ALJ's decision, you can appeal within 60 days of the date on the ALJ decision to the MAC. The MAC can also review the ALJ decision on its own initiative. If you disagree with the MAC's decision or if the MAC denied the request for appeal, and the amount in question meets the minimum amount that is adjusted annually ($1,400 in 2013), you can request review by a federal court.
If your plan denies you again, there are several higer levels of appeal:
Independent Review Entity (IRE) review
Administrative Law Judge (ALJ) hearing
Medicare Appeals Council (MAC) review
If the IRE, ALJ, MAC or federal court decides the plan must cover the drug you need, the plan must process the coverage within 72 hours (24 hours for an expedited appeal) from the date the plan receives the decision. If the case involves a reimbursement request, the plan must authorize reimbursement within 72 hours and pay within 30 calendar days from the date it receives the decision. If your plan does not process the coverage or issues reimbursement within these timeframes, file a complaint with your plan and notify Maximus Federal Services.