If Your Medicare Part D (Prescription Drug Coverage) Claim Is Denied

If you encounter issues with your Medicare Part D prescription drug plan, you have 4 options. A Health Insurance Counseling & Advocacy Program (HICAP) counselor may be able to help you with these issues. Find your local HICAP office online.

Topics on this page:

• Coverage Determinations
• Exceptions
• Appeals
• Complaints/Grievances

You may appoint someone else — a family member, friend, caregiver or doctor — to be your representative in an appeal or complaint.

Note: Complaints/grievances are not part of the appeals process outlined below. They are intended for complaints about your Part D plan that don't involve coverage or payment issues.

Coverage Determinations

If your pharmacist notifies you that your Medicare prescription drug plan:

• Won't cover a drug you think should be covered
• Requires you to get prior approval for your drugs
• Requires you to try another drug before it will pay for the drug first prescribed
• Limits the quantity or dose of the drug prescribed
• Will cover the drug prescribed, but only at a higher cost than you think you should pay

Then you have 2 options:

1. Request a coverage determination from your plan, or
2. Pay for the prescription and then request reimbursement through a coverage determination.

You, your doctor, family member or other appointed representative (call your plan to learn how to appoint a representative) can call your plan or write a letter requesting that the plan cover the prescription you need.

Once the request is received, the plan has 24 or 72 hours to notify you of its decision, depending on the type of request made:

• Expedited Request: The plan has 24 hours if you submit an expedited request for coverage. Your request will be expedited if your doctor notifies your plan that your life or health will be seriously jeopardized by waiting for a standard decision. Your request can also be expedited at the discretion of the plan if you request the faster review yourself without your doctor's support.
• Standard Request: The plan has 72 hours if you submit a standard request for coverage or reimbursement.

If you submit an expedited request, the plan may initially notify you of its decision within 24 hours by phone, but it must also send you a written coverage determination letter within 3 days. If the plan does not send you written notice of its expedited determination within this time, it must send your request to the Independent Review Entity (IRE). Learn more.

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Exceptions

An exception is a type of coverage determination request that requires you to submit a supporting statement from your doctor explaining why you need the drug you are requesting.

You may request an exception from your Medicare prescription drug plan if:

• You are taking a drug that has been removed from the plan's formulary.
• A non-formulary drug is prescribed and medically necessary.
• The copayment for a drug you are taking increases and you cannot afford it.
• You want the plan to cover a non-preferred drug at the preferred drug cost.

In general, an exception request must be granted if:

1. The plan determines the medication is medically necessary; and
2. The prescribing doctor determines at least 1 of the following to be true:
   • None of the drugs on the formulary would be as effective as the non-formulary drug.
   • Any other drug would have adverse effects.

Once an exception is granted, it remains in effect for the calendar/plan year, as long as your doctor continues the prescription. If you renew your enrollment in the same Medicare drug plan at the end of the year, you may be required to submit a new exception request.

If the drug plan denies coverage, it must notify you (and your doctor, if he/she made the exception request) in writing within 72 hours, explaining the reason for denial and how to continue the appeals process.

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Appeals

If the plan's coverage determination is not in your favor, you can appeal the decision. When you join a Medicare prescription drug plan, you will receive information about the plan's appeal procedures. Keep this information where you can find it in case you need it. You can also call your drug plan for instructions.

The 5 levels of appeal are described below:

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Complaints/Grievances

If you have a complaint about your Medicare prescription drug plan that doesn't involve coverage or payment for a covered drug, you have the right to file a grievance.

You should file your grievance within 60 days of the event in question. Grievances can arise from dissatisfaction with any aspect of a drug plan's operations, activities or behavior. For example, you might file a grievance if:

• You have to wait too long for your prescriptions at the plan's pharmacy.
• The plan did not make a decision within the required timeframe.
• You have trouble reaching the plan's customer service department.
• The pharmacy is charging you more than you think you should pay (in this case, call the drug plan to get the most up-to-date price).

The plan must notify you of its decision within 30 days of receipt of the grievance, although this timeframe can be extended at your request, or if the plan can show that a delay would benefit you.

If the plan doesn't resolve your grievance, call 1-800-MEDICARE.

Quality of care complaints concerning your Medicare prescription drug plan can also be filed with Health Services Advisory Group (HSAG), California's Quality Improvement Organization (QIO). Contact HSAG online or by phone at 1-800-841-1602 or 1-800-881-5980 (TDD for the hearing impaired).

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