If this happens to you there are options for you take depending on the reason for the denial. When your Part D plan will not pay for your drug, you should receive a notice at the pharmacy titled Medicare Prescription Drug Coverage and Your Rights. This notice provides instructions on filing an exception request with your plan, which is the first step of the appeal process. (Note that this initial notice is not a formal denial).
Follow the steps below to learn more about why your drug was not covered and to begin the appeal process—the steps apply whether you have a stand-alone Part D plan (PDP) or a Medicare Advantage Plan with Part D coverage.
Remember, Medicare Part D provides outpatient drug coverage. Part D is provided only through private insurance companies that have contracts with the federal government—it is never provided directly by the government (unlike Original Medicare).
Call your plan to find out the reason it is not covering your drug. If the plan made an error, they should correct it. Ask your plan the following questions:
- Is my drug on the plan’s formulary? A formulary is a list of prescription drugs that the Part D plan will cover. Drugs not covered on the formulary are generally not paid for by the plan. Plan formularies can change each year.
- Does my drug have a coverage restriction (requirement you must meet before you can get your drug, such as step therapy or quantity limits)?
- Am I using an in-network pharmacy?
The phone number for your Part D plan is written on the back of your plan benefit card.
Once you know why your drug was not covered at the pharmacy, speak to your prescribing doctor or other provider about your options.
- Make sure you are using an in-network pharmacy.
- 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 file an exception request. Ask your doctor to write a letter of support to send to your plan requesting an exception to the plan’s rules. This letter should explain why you need the drug and, if possible, how other medications to treat the same condition are dangerous or less effective for you.
Note: 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.
There are several reasons your drug could be denied. Contact your Medicare consultant or adviser for additional help and guidance. Your prescriptions can change each year and your current plan may not meet your needs at the current time. It is important to review your healthcare requirements with your Medicare consultant annually to ensure your current plan is meeting current needs. You have an opportunity to make changes in your coverage during the annual Enrollment Period that begins October 15 and ends December 7th each year. The effective date for any change will be January 1.
Kenneth Kiker, CHC spent 49 years in the insurance industry before retiring in 2011 after working in United Healthcare’s Tucson office for 6 years specializing in their Medicare division. He continues to work with Medicare beneficiaries helping them with their Medicare coverage decisions. Ken achieved his Certified Health Consultant (CHC) designation in 1990 after attending The CHC School of Marketing at Purdue University and passing a series of national program exams. Email: firstname.lastname@example.org