If you were denied coverage for a prescription drug, you should ask your plan to reconsider its decision by filing an appeal. The appeal process is the same in stand-alone Part D plans and Medicare Advantage Plans with Part D coverage. Follow the steps below if your plan denied coverage for your prescription. If you need your prescription immediately, file a fast (expedited) appeal.
If your appeal is successful at any point outlined below, your plan should cover the drug in question until the end of the current calendar year. Be sure to ask your plan if they will cover the drug after the year ends. If they will not, you can appeal again next year or consider switching during the Fall Open Enrollment Period to a Part D plan that does cover your drug.
While following the steps below, make copies of all the documents you send to and receive from your plan, and take detailed notes about who you talk to at your plan, when you spoke to them, and what they said.
- If your pharmacist tells you that your plan will not pay for your prescription drug, the pharmacist should give you a notice titled Medicare Prescription Drug Coverage and Your Rights. First, call your plan to find out the reason it is not covering your drug. Your plan may deny coverage because your drug is not on its formulary, or because a coverage restriction imposes requirements you must meet before you can get your drug. Keep in mind that you have not received a denial notice from your plan yet, meaning you have not started a formal appeal.
- Once you know why you drug was not covered at the pharmacy, speak to your prescribing physician or other provider about your options. For example, you may be able to try a comparable drug that is on the formulary. If switching to another drug is not an option, you can choose to appeal. Your provider may appeal on your behalf or help you with the appeal process, but is not required to do so.
- Before you start the appeal process, you 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. Your doctor may file on your behalf but is not required to do so. Your plan should issue a decision within 72 hours.
- You can request a fast (expedited) exception request if you or your doctor feel that your health could be seriously harmed by waiting the standard timeline for a decision. If your doctor supports your decision to file an expedited exception request, the plan must follow the expedited timeline. You can request an expedited exception request without your doctor’s support, but in this case your plan does not have to follow the expedited timeline. If the plan grants your request to expedite the process, you will get a decision within 24 hours of the initial request.
- If your exception request is approved, your drug will be covered. If your exception request is denied, your plan should send you a 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. This timeline applies regardless of whether your appeal is under standard or expedited review. Follow the directions on the notice. If a doctor is not appealing on your behalf, you may want to ask your doctor to write a letter of support addressing the plan’s reasons for not covering the needed drug. Your plan should issue a decision within seven days. If you are filing an expedited appeal, the plan should issue a decision within 72 hours.
- 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 by appealing to the Independent Review Entity (IRE) within 60 days of the date listed on your appeal denial. The IRE should issue a decision within 7 days. If you are filing an expedited appeal, the IRE should issue a decision within 72 hours.
- If the IRE approves your appeal, your drug will be covered. If your appeal is denied and your drug is worth at least $160 in 2017, you can choose to appeal to the Office of Medicare Hearings and Appeals (OMHA) level within 60 days of the date on your IRE denial letter. You may want to contact a lawyer or legal services organization to help you with this or later steps of your appeal—but it is not required. OMHA should issue a decision within 90 days. If you are filing an expedited appeal, OMHA should issue a decision within 10 days.
- If your appeal to the OMHA level is successful, your drug will be covered. If your appeal is denied and your drug is worth at least $160 in 2017, you can choose to appeal to the Council within 60 days of the date on your OMHA level denial letter. The Council should issue a decision within 90 days. If you are filing an expedited appeal, the Council should issue a decision within 5 days.
- If your appeal to the Council is successful, your drug will be covered. If your appeal is denied and your drug is worth at least $1,560 in 2017, you can appeal to the Federal District Court within 60 days of the date on your Council denial letter. There is no timeframe for the Federal District Court to make a decision about your appeal.