The Medicare Prescription Drug Coverage and Your Rights notice

When your Part D Part D Part D, also known as the Medicare prescription drug benefit, is the part of Medicare that provides prescription drug coverage. Part D is offered through private companies either as a stand-alone plan, for those enrolled in Original Medicare, or as a set of benefits included with a Medicare Advantage Plan. plan will not pay for your drug, you should receive a notice at the pharmacy titled Medicare Prescription Drug Coverage and Your Rights. This notice provides instructions on filing an exception request exception request An exception request is a formal written request to your Part D plan asking that it pay for a drug you need. For example, you can file an exception request to pay for a drug that is not on the plan’s list of covered drugs (formulary), or you can ask the plan to lower the cost of an expensive drug on the formulary (see Tiering Exception). with your plan. Note that even though your plan will not pay for the medication, this initial notice is not a formal denial.

Call your plan to find out the reason it is not covering your drug. If your plan made an error, they should correct it. If not, there are a few common reasons a plan may deny payment:

• Prior Authorization Prior Authorization Prior authorization, also known as pre-authorization or pre-approval, is a restriction placed on coverage by Part D plans and Medicare Advantage Plans. If a service or drug requires prior authorization, you must first get approval from the plan for it to be covered. If you fail to get prior authorization before you get the service or drug, your plan generally will not cover it. : you must get prior approval from the plan before it will cover a specific drug
• Step Therapy Step Therapy Step therapy is a restriction placed on drug coverage by Part D plans and Medicare Advantage Plans. Before your plan will cover a drug, you must first try a different or less expensive drug that treats your condition to see if it will be effective for you. : your plan requires you try a different or less expensive drug first
• Quantity limits: your plan only covers a certain amount of a drug over a certain period of time, such as 30 pills per month
• Off- Formulary Formulary The formulary is the list of prescription drugs covered by a Part D plan or Medicare Advantage Plan. If your drug is not on the formulary, you may have to request an exception, file an appeal, or pay out of pocket. : the drug is not on your plan’s list of covered drugs

If your plan denied your drug 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 why you need the drug and, if possible, how other medications to treat the same condition are 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 could be seriously harmed by waiting the standard timeline, you or your doctor can request an expedited decision, and you should receive this decision from your plan within 24 hours.

If your plan approves your exception request, your drug should be covered until the end of the current calendar year. If your exception request is denied, you can choose to appeal.

For more information on the Medicare Prescription Drug Coverage and Your Rights notice, please call your plan or 1-800-MEDICARE (633-4227).