What do I do if my plan won’t cover a drug I need?

You, your doctor, or your appointed representative can ask the plan to cover the prescription you need by calling your plan or writing them a letter. If you write to the plan, you can write a letter or use the "Model Coverage Determination Request" form. You can get a copy of this form by visiting www.cms.hhs.gov/MedPrescriptDrugApplGriev/13_Forms.asp on the web.

If you want to appoint a representative to help you with a coverage determination or appeal, you and the person you want to help you should complete the "Appointment of Representative" form (Form CMS-1696) and send it with your coverage determination or appeal request. You can get a copy of this form by visiting www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf on the web.

You may file either a standard or an expedited (fast) coverage determination request. Your request will be expedited if your plan determines, or your doctor tells your plan, that your life or health may be seriously jeopardized by waiting for a standard request. Once your plan has received the request, it has 72 hours (for a standard request for coverage or for a request to pay you back) or 24 hours (for an expedited request for coverage) to notify you of its decision.

Tip: Any person you appoint, such as a family member or your physician, may help you request a coverage determination or an appeal.

Important: For some types of coverage determinations called exceptions, you will need a supporting statement from your doctor explaining why you need the drug you are requesting. You may need this statement for any of the following:

• You are asking the plan to cover a drug that isn’t on its drug list (formulary).
• You want the plan to cover a non-preferred drug at the preferred drug price.
• Your doctor believes that you can’t meet one of your plan’s coverage rules, such as a prior authorization, quantity limit, or dose limit.

Check with your plan to find out if the supporting statement is required, and if it must be in writing. If a supporting statement is required, the plan’s decision-making time period begins once your plan receives the statement.

Once your plan has received your request (and supporting statement if required), it has 72 hours (for a standard request for coverage or for a request to pay you back) or 24 hours (for an expedited request for coverage) to notify you of its decision.

(Primary Source: Centers for Medicare and Medicaid Services - Your Guide to Medicare Prescription Drug Coverage 2008. This content may have been enhanced by Q1Group LLC to include further examples, explanations, and links.)