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. The notice is called the Medicare Prescription Drug Coverage and Your Rights Notice. It provides a general set of guidelines for overcoming the stop on coverage. Even though your plan will not pay for the medication, this paper is not a formal denial.
The denial could be an error made by your Part D plan or the pharmacy. To find out if you were denied payment because of an administrative error, call your Part D plan. When you call your plan, be ready to discuss the topics outlined at the bottom section of the notice including, the prescription drug that’s not being paid for, your pharmacy and the date you tried to fill the prescription.
If the payment stop is an administrative error, it should be lifted by your plan.
If payment stop 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 because of 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.
Remember, if you need a decision about your drug immediately because your health would be jeopardized by a long appeal process, your doctor can request an expedited appeal.
For more information on the Medicare Prescription Drug Coverage and Your Rights Notice, please call your plan, or 800-Medicare.
Please click here for more information on the Part D appeals process.