Dear Tony,

There are several reasons that your Part D plan might refuse to pay for your drug. Some of the most common reasons are:

• Your drug is off formulary: The drug is not on your plan’s list of covered drugs.
• Prior authorization: You must get approval in advance from your plan before it will cover a specific drug.
• Step therapy: Your plan requires you to try a different (usually less expensive) drug first.
• Quantity limits: Your plan only covers a certain amount of a drug over a certain period (like 30 pills per month).

To find out the reason, you can contact the plan and request a coverage determination, or a formal decision about paying for the drug. Once you know the reason that your drug has been denied, you’ll be able to work with your doctor to communicate with the plan. Your doctor may need to submit additional evidence or information. For example, if your drug is denied because of a step therapy requirement, your doctor may need to submit documentation that you’ve already tried the other, drugs the plan covers to treat your condition. If you and your doctor think that trying the alternative drugs would be dangerous or ineffective for you, you can request an exception to the step therapy rule by filing an appeal.   Similarly, if the drug is denied because it is off formulary, you can ask your provider whether the formulary alternatives would be appropriate for you, and, if not, you can request a formulary exception.

There are some reasons that your drug might be denied where you are less likely to obtain a favorable decision through an appeal. In these situations, you still have the right to appeal, but the odds of a successful outcome are lower.

• Your drug has been prescribed for an off-label use: “Off-label” is a term used to describe situations where a doctor has prescribed a drug for a reason other than the use(s) approved by the U.S. Food and Drug Administration (FDA) or listed in certain medical reference texts. If your doctor prescribes a medication on your plan’s formulary for a reason other than the use approved by the FDA, your drug will probably not be covered unless it fits into certain narrow categories.
• Your drug is excluded from Medicare coverage: Some drugs or specific uses of drugs are excluded from Medicare coverage.

Again, your first step should be to contact your plan to learn why it isn’t covering your medication. Learning the reason for denial is important as you consider your next best step.

I hope this helps!

-Marci