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How to Request a Medicare Part D Coverage Determination, File an Appeal, or File a Complaint

As an introduction, there are two ways to get Medicare prescription drug coverage:
  1. Medicare Prescription Drug Plans (Part D) These plans (sometimes called PDPs) add drug coverage to Original Medicare,some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, andMedicare Medical Savings Account (MSA) Plans.

  2. Medicare Advantage Plans (like an HMO or PPO) or other Medicare healthplans that offer Medicare prescription drug coverage You get all of your Medicare Part A (Hospital Insurance), Medicare Part B (MedicalInsurance), and prescription drug coverage (Part D) through these plans. MedicareAdvantage Plans with prescription drug coverage are sometimes called MA-PDs.

Medicare doesn’t cover (pay for) all prescription drugs. Each Medicare drug plan has its own list of drugs (called a "formulary") that are covered by the plan. The formulary will include generic and brand-name drugs. The plan’s formulary must meet Medicare’s requirements. Check to see if the plan covers your prescription drugs. Browse Any Medicare PDP Formulary

Even if a drug is on the plan’s list, there may be special rules for filling a prescription. For example, you or your prescriber may need to get permission from the plan (prior authorization) to use the drug before it is covered. The plan may ask you to try another drug before it will cover the drug that was prescribed for you (step therapy). Also, the plan may limit the number of pills or dose prescribed (quantity limits). See How Your Drug is Handled by all PDP Plans

In addition to these special rules, the plan’s formulary can change during the year because drug therapies change, and new drugs and medical knowledge become available. If there is a formulary change that affects a drug you take, your plan will notify you at least 60 calendar days in advance. You will then have an opportunity to request an exception. See below for more information.

There may be times when you disagree with a coverage or payment decision made by your Medicare drug plan. This section explains your options and the steps you need to take if you disagree with your Medicare drug plan.

Important changes to Chapter 18 of the Prescription Drug Benefit Manual Part D Grievances, Coverage Determinations, and Appeals:
  • A disagreement about TrOOP (Ture Out-of_Pocket) calculation that result from dispute over low-income subsidy eligibility cannot be resolved under the Medicare Part D coverage determination and appeals processes. Instead, such dispute must be resolved with the agency responsible for making the determination (20.2.2 Co-Payment Complaints)

  • An enrollee who requests a Utilization Management exception and receives an approval, may also request a tiering exception for the same formulary drug(30.2.2 Formulary Exceptions)

  • A decision by a plan sponsor to reimburse an enrollee (or deny reimbursement) is a coverage determination. (30.3 Requests for Reimbursement)

  • Plan sponsor must accept all reimbursement requests made in writing, and cannot require use of a specific form. (30.3.1 Form and Content of Reimbursement Requests)

  • Plan sponsors must not send standard denial notices to enrollees when decisions aren’t made timely (instead, plan sponsors must notify enrollees that their cases have been sent to the IRE for review). (40.4 Effect of Failure to Provide Timely Notice and 50.5 Notification of the result of an Adverse Expedited overage Determination)

  • An enrollee’s physician can request a standard redetermination without being an enrollee’s representative so long as the physician provides notice to the enrollee. (70.1 Who May Request a Redetermination)

  • Favorable coverage determination or appeal decisions are retroactive to the date of the earliest request or prescription purchase approved in a coverage determination or appeal decision. Also added examples. (130 Effectuating Favorable Decisions)

Tips & Disclaimers
  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.