Want to learn what to do when a medication isn’t covered? Download this handout for tips.

Part D appeals at a glance:

• If your plan won’t cover your medication, you can appeal the decision.

• The process is the same whether you get your drug coverage through a stand-alone Part D plan or a Medicare Advantage Plan.

• Instructions for how to appeal will always be on your denial notice.

• Your doctor can appeal on your behalf or write a letter of support to help your appeal, but they aren’t required to do so.

• There is more than one level of appeal, and you have the right to continue appealing if you aren’t successful at the first level.

• Keep documentation throughout and pay attention to deadlines.

Start with an exception request

If your plan won’t cover your prescription drug, your pharmacist should give you a notice called Medicare Prescription Drug Coverage and Your Rights.

After getting this notice, call your plan to find out the reason it isn’t covering your drug. For example:

• The drug isn’t on the plan’s list of covered drugs.
• You may need to request approval from the plan before it will cover that drug.
• Your plan may require that you try a different, usually less expensive drug first.
• Your drug has been prescribed for off-label use.

Start with an exception request, continued

Once you know why your drug isn’t covered, speak to your prescribing physician about your options. For example, you may be able to try a comparable drug that your plan does cover.

If switching to another drug isn’t an option, you’ll need to file an exception request with your plan. This is a formal coverage request, and you can contact your plan to learn how to file one. You should ask your doctor for a letter of support for your exception request.

If your request is approved, your drug will be covered. If it’s denied, your plan will send you a Notice of Denial of Medicare Prescription Drug Coverage. This is your formal denial notice from the plan, and now you can choose to begin a formal appeal.

The Part D appeals process

You have 60 days from the date listed on this notice to file an appeal. Directions on how to appeal are on your denial notice. Your provider may appeal on your behalf or help you with the appeal process, but they aren’t required to do so. If a doctor is not appealing on your behalf, you should ask them to write a letter of support addressing the plan’s reasons for not covering your drug. 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 of appeal.

There are four levels of appeal after this initial step. At each level, if you are denied, follow the instructions on the denial notice to submit your next appeal. Follow all deadlines carefully. If your appeal is approved at any point, your Part D plan should cover your drug until the end of the calendar year. Be sure to ask your plan if they will continue to cover the drug after the year ends. If they will not, you can appeal again next year, or consider switching Part D plans during Medicare’s Open Enrollment Period to a plan that does cover your drug.

If you need help understanding the appeals process, call your local State Health Insurance Assistance Program (SHIP). A SHIP Medicare counselor can provide you more information and guide you through the process. See the last page of the document this information was pulled from for their contact information. 

Read your Medicare statements to find potential fraud, errors, or abuse.

An Explanation of Benefits (EOB) is the statement that your Medicare Advantage Plan or Part D prescription drug plan typically sends you after you receive medications, services, or items. An EOB is not a bill.

An EOB is also different from a Medicare Summary Notice (MSN), which you receive if you have Original Medicare. You may receive both statements if you have Original Medicare and a stand-alone Part D plan—an MSN for your Original Medicare and an EOB for your Part D plan.

Let’s learn more about EOBs:

• Your EOB is an summary of the medications, services and items you have received. It tells you how much your provider billed, the approved amount your plan will pay, and how much you may owe the provider.

• EOBs are usually mailed once per month, but some plans give you the option of accessing your EOB online.

• If you keep a record of your appointments, tests, and receipts for services and items received with your SMP My Health Care Tracker, you can compare your EOBs to what you recorded in your tracker.

• It’s important to read your EOB as soon as you receive it to ensure you actually received all the medications, services, or items listed.

• If you spot a potential billing mistake or error, first contact your provider so they can make corrections.

If potential errors are not corrected by your provider, contact your Senior Medicare Patrol (SMP). The SMP program empowers and assists Medicare beneficiaries, their families, and caregivers to prevent, detect, and report health care fraud, errors, and abuse.

Who to contact for more information

Your doctor or other health care provider: Discuss other options for your medication. If that is not available, ask for your doctor’s support in submitting an exception request and then filing an appeal.

Medicare Advantage Plan/Part D plan: If you are denied coverage at the pharmacy, contact your plan to learn why the drug isn’t being covered.

State Health Insurance Assistance Program (SHIP): A Medicare counselor at your SHIP can guide you through the steps of the appeals process.

Senior Medicare Patrol (SMP): Contact your SMP if you have experienced potential Medicare fraud, errors, or abuse. SMPs can help and provide you with information to prevent, detect, and report such experiences.

Local SHIP contact information:

Toll Free: 1-866-413-5337 | Email: shineinfo@aaaswfl.org

Website: www.floridashine.org

To find a SHIP in another state: Call 877-839-2675 (a say “Medicare” when prompted) or visit www.shiphelp.org.

SHIP Technical Assistance Center: 877-839-2675 | www.shiphelp.org | info@shiphelp.org
SMP Resource Center: 877-808-2468 | www.smpresource.org | info@smpresource.org
© 2023 Medicare Rights Center | www.medicareinteractive.org |

The Medicare Rights Center is the author of portions of the content in these materials but is not responsible for any content not authored by the Medicare Rights Center. This document was supported, in part, by grant numbers 90SATC0002 and 90MPRC0002 from the Administration for Community Living (ACL), Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.

Depending on your coverage, you will have different considerations when choosing health care providers like doctors, hospitals, or medical equipment suppliers. Follow this link to review some of these factors, so you can get your care covered at the lowest cost. 

Even with this information in hand, remember to trust yourself and your feelings when choosing your health care providers. For instance, just because a provider is in network doesn’t mean they will be a good fit for you. You may have to try multiple providers before finding one who you trust and who fits your needs.

If you have Original Medicare, choose a participating provider.

There are three types of providers, and each has a different relationship with Medicare. To pay the least for your care, see a participating provider when possible.

Participating providers accept Medicare and always take assignment. Taking assignment means that the provider accepts Medicare’s approved amount for health care services as full payment. Participating providers must submit a bill to Medicare when you receive care. Medicare then processes the bill and pays the provider 80% of the cost of your care. You are then responsible for the other 20% of the cost.

Non-participating providers, on the other hand, accept Medicare, but do not have to take assignment. This means they can charge up to 15% more than Medicare’s approved amount for services. In other words, you could owe up to 35% of the cost of Medicare’s approved amount for services instead of just 20%.

Opt-out providers do not accept Medicare at all. These providers have signed an agreement to be excluded from the Medicare program. Medicare will not pay for care you receive from an opt-out provider, except in emergencies, and will not reimburse you. These providers can charge whatever they want for services, following certain rules.

Choosing Doctors and Other Providers

If you have Medicare Advantage, choose an in-network provider.

A network is a group of doctors, hospitals, and medical facilities that contracts with a plan to provide services. Each type of Medicare Advantage Plan has different network rules. There are various ways a plan may manage your access to specialists or out-of-network providers. For example, if you see a provider who is outside your plan’s network, you may have to pay more than you would for an in-network provider. You could also be responsible for paying the full cost of your visit, depending on what type of Medicare Advantage Plan you have.

Remember that your costs are typically lowest when you use in-network providers and facilities, regardless of your plan type. It’s important to note that not all Medicare Advantage Plans work the same way. Make sure you understand a plan’s network and coverage rules before enrolling. If you have questions, contact your plan for more information.

If you have Part D, choose an in-network pharmacy and look for pharmacies with preferred cost sharing.

Part D plans generally have networks of pharmacies that they contract with to provide you with covered medications. Many pharmacy networks include pharmacies that offer lower “preferred” cost sharing. You typically pay less for your prescriptions at these pharmacies. If you need to find in-network pharmacy or if you have any issues accessing your covered medications at the pharmacy, contact your Part D plan.

Need help finding doctors and other providers?

• If you have Original Medicare: Call 1-800-MEDICARE (633-4227) or use Medicare’s online Care Compare tool.
• If you have Medicare Advantage: Contact your plan for a list of in-network providers.
• For more assistance, contact your State Health Insurance Assistance Program (SHIP). In Southwest Florida, that is SHINE (Serving Health Insurance Needs of Elders), call 1-866-413-5337 or email shineinfo@aaaswfl.org.

To learn more click here.

SHINE is here to help. To learn about other counseling options, call the Helpline at 866-413-5337.
SHINE counselors are available Monday – Friday to assist you with Medicare’s Open Enrollment and all matters related to Medicare including access to preventive services, cost-saving programs and identifying and reporting Medicare fraud.

To prepare for your SHINE counseling session, review this handout.
Please complete the form and have it available for your counseling session.