Denied Medicare Part D coverage? You can appeal
January 1, 2024 | View PDF
While I am writing this month’s article, we are in the last few days of the annual Open Enrollment Period, when you may sign up to change your enrollment in a Medicare Part D Prescription Drug Plan. This period occurs annually from Oct. 15 through Dec. 7; changing your plan at other times of the year may require you to be eligible for a Special Enrollment Period. But what if you don’t meet this requirement, and your prescription drug cost share (the amount you pay when you pick up the prescription from the pharmacy) costs too much or worse, what if your plan does not cover your prescription? You have the right to appeal any decision.
Understand your right to appeal
If your Part D plan denies coverage of your medication, you may appeal the decision. A Part D appeal is a formal request for review of a coverage decision made by your Part D plan. 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. Be aware that at each level of appeal, there’s a separate timeframe for when you must file the appeal and when you will receive a decision.
Pay close attention to the paperwork you receive, and feel free to call the State of Alaska’s Medicare Information Office for help in understanding your appeal process.
File an exception request
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 isn’t covering your drug. There are various reasons why a plan might do this, and knowing the reason is very important to your appeal. Here are a few examples of reasons why a Part D plan may deny coverage:
The drug is not on your plan’s list of covered drugs (the formulary).
You may need to request approval from the plan before it will cover your prescription. This is known as prior authorization.
Your plan requires that you try a different, usually less expensive drug first. This is known as step therapy.
Your drug has been prescribed for off-label use. This means that your doctor has prescribed the drug for a reason other than the uses approved by the Food and Drug Administration (FDA).
Once you know why your drug wasn’t covered at the pharmacy, speak to your prescribing provider 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 request for your plan to cover your drug. Contact your plan to learn how to file one. Ask your doctor to provide a letter of support that directly addresses the denial reason. 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 begin a formal appeal.
How to appeal the decision
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 first 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.
None of us has a crystal ball, nor a time machine, so we make the best decisions we can at the time we make them. If you find yourself overwhelmed by any Medicare issue, please feel free to contact the State of Alaska Medicare Information Office at 800-478-6065 or 907-269-3680; our office is also known as the State Health Insurance Assistance Program (SHIP), the Senior Medicare Patrol (SMP), and the Medicare Improvements for Patients and Providers Act (MIPPA) program.
If you are part of an agency or organization that assists seniors with medical resources, consider networking with the Medicare Information Office. Call us to inquire about our new Ambassador program.
Sean McPhilamy is a volunteer and Certified Medicare Counselor for the Alaska Medicare Information Office.