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:- 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.
- 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.
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.
- Requesting a Coverage Determination or Exception
- How to Appeal a Coverage Decision
- Appealing the Late Enrollment Penalty
- How to File a Medicare Part D Complaint
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)