Medicare Minute: Part D Appeals – What to do when your medication isn’t covered
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: email@example.com
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 | firstname.lastname@example.org
SMP Resource Center: 877-808-2468 | www.smpresource.org | email@example.com
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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.