If your Medicare drug (Part D) plan denies coverage for a drug you need, you can appeal the decision.
The insurers offering Medicare drug plans choose both brand-name and generic medicines that they will include in a plan’s “formulary.” This is the roster of drugs the plan covers and will pay for, and it changes year-to-year. If a drug you need is not in the plan’s formulary or has been dropped, the plan can deny coverage. Plans may also charge more for a drug than you think you should have to pay or deny you coverage for a drug in the formulary because the plan doesn’t believe you need the drug. If any of these things happens, you can appeal.
Before you can start the formal appeals process, you need to file an exception request with your plan. Contact your plan to obtain instructions on how to request an exception. The plan must respond within 72 hours, or within 24 hours if your doctor says that waiting 72 hours would be seriously detrimental to your health. If your exception is denied, the plan should send you a written denial-of-coverage notice and the five-step appeals process can begin.
- The first step in appealing a coverage determination is to go back to the insurer and ask for a redetermination, following the instructions provided by your plan. You should submit a statement from your doctor or prescriber that explains why you need the drug you are requesting, along with any medical records to support your argument. If your doctor informs the plan that you need an expedited decision due to your health, the plan must respond within 72 hours. For a standard redetermination, the plan must respond within seven days.
- If you disagree with the drug plan’s decision, you have the right to reconsideration by an independent board. To request reconsideration, follow the instructions in the written redetermination notice you receive from the insurer. You have 60 days to make your request. An independent review entity will review the case and issue a decision either within 72 hours or seven days.
- If you receive a negative decision, you can keep appealing. The third level of appeal is to request a hearing with an administrative law judge (ALJ), which allows you to present your case either over the phone or in person. To request a hearing, the amount in controversy must be at least $160 (in 2018). The amount in controversy is calculated by subtracting any amount already covered under Part D and any applicable deductible, co-payments, and coinsurance amounts from the projected value of the benefits in dispute. Your request for a hearing must be sent in writing to the Office of Medicare Hearings and Appeals. The ALJ is supposed to issue an expedited decision within 10 days or a standard decision within 90 days.
- If the ALJ does not rule in your favor, the next step is a review by the Medicare Appeals Council. The appeal form must be filed within 60 days after the ALJ’s decision. You will need a statement explaining why you disagree with that decision. The appeals council will issue an expedited decision in 10 days or a standard decision within 90 days.
- The final step is review by a federal trial court. To be able to request review, the amount in controversy must be $1,600 (in 2018). Follow the directions in the letter from the appeals council and file the request in writing within 60 calendar days.
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