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Sometimes a Part D plan won’t cover a medication that you need. Let’s discuss what you can do if this happens.

First, understand your right to appeal.

A Part D appeal is a formal request for review of a coverage decision made by your Part D plan. If your Part D plan denies coverage of your medication, you may appeal the decision. The appeals process will be the same whether you get your drug coverage through a stand-alone Part D plan or as part of your Medicare Advantage 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.

Note that there is a difference between an appeal and a grievance. If you have a problem with your Part D plan that isn’t a formal request for them to cover a drug, you can file a grievance. For example, if your plan has poor customer service or fails to deliver a promised refund. In some cases, you may want to file both an appeal and a grievance. Contact your plan to file a grievance.

File an exception request if your Part D plan will not cover your drug at the pharmacy.

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 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. This is called prior authorization.
  • Your plan may require that you try a different, usually less expensive drug first. This is called 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 FDA. If this final example is the case, be aware that you can appeal for coverage, but you are less likely to receive a favorable decision.

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 coverage request, and you can contact your plan to learn how to file one. Your doctor should provide 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.

Know how to start your Part D appeal.

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 Fall Open Enrollment to a plan that does cover your drug.

Still have questions?  

Your SHIP is here for you! You can contact your SHIP for any Medicare-related questions or concerns you have. SHIP counselors are government funded to provide trusted, unbiased Medicare counseling at no cost to you. (Depending on your state, your SHIP may go by another name.) Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to find your local SHIP.

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