Medicare Presciption Drug Coverage and Your Rights: Why is My Medication Not Covered?

This is a frequent question for Medicare Part D members: "Why is my medication not covered?" This question is simple, but the answer has become increasingly complicated as different plan sponsors choose to create their own proprietary formularies. Though there is a set of standards for Medicare Part D plans to follow in terms of what they must cover, there are instances that patients may be denied coverage on a medication they thought/feel should be covered.Medicare Prescription Expenses

One tool that is available to find out what Medicare Part D plans maintain your medicine within their formulary is through Medicare.gov. This site was developed to help to avoid situations in which patients sign up for coverage without information on how their medications lie within (or without) the plan formulary.

This is a new medicine that I think should be covered...

Should this be your situation you have some options:
(these options can be found in Chapter 5 pages 39-49 in the CMS Medicare Appeals Booklet, and for your convenience, have been outlined below)

1. Talk to your prescriber.
Ask your prescriber if you meet prior authorization or step therapy requirements. For more information on these requirements, visit www.medicare.gov/Publications to view or print the fact sheet “How Medicare Prescription Drug Plans and Medicare Advantage Plans with Prescription Drug Coverage (MA-PDs) Use Pharmacies, Formularies, and Common Coverage Rules,” or call 1-800-MEDICARE (1-800-633-4227) and ask for a free copy. TTY users should call 1-877-486-2048. You can also ask your prescriber if there are generic, over-the-counter or less expensive brand name drugs that could work just as well as the ones you’re taking now.
2. Request a coverage determination (including an "exception")
You, your representative, your doctor, or other prescriber can request (orally or in writing) that your plan cover the prescription you need. You can request a coverage determination if your pharmacist or plan tells you one of the following:
  • A drug you believe should be covered isn’t covered;
  • A drug is covered at a higher cost than you think you should have to pay;
  • You have to meet a plan coverage rule (such as prior authorization) before you can get the drug you requested; or,
  • It won’t cover a drug on the formulary because the plan believes you don’t need the drug.
You, your representative, your doctor, or other prescriber can request a coverage determination called an "exception" if:
  • You think your plan should cover a drug that’s not on its formulary because the other treatment options on your plan’s formulary won’t work for you;
  • Your doctor or other prescriber believes you can’t meet one of your plan’s coverage rules, such as prior authorization, step therapy, or quantity or dosage limits;
  • You think your plan should charge a lower amount for a drug you’re taking on the plan’s non-preferred drug tier because the other treatment options in your plan’s preferred drug tier won’t work for you.

If you request an exception, your doctor or other prescriber will need to give a supporting statement to your plan explaining why you need the drug you’re requesting. Check with your plan to find out if the supporting statement is required and if it must be made in writing. The plan’s decision-making time period begins once your plan gets the supporting statement.

You can either request a coverage determination before you pay for or get your prescriptions, or you can decide to pay for the prescription, save your receipt, and request that the plan pay you back by requesting a coverage determination.

You can either file a standard request or a fast request for the coverage determination. See timeframes below.

How do I file a standard coverage determination?

You, your representative, your doctor, or other prescriber can request a coverage determination (including an exception) by following the instructions that your plan sends you. Once your plan has gotten your request, it has 72 hours to notify you its decision. You can call your plan, write them a letter, or send them a completed “Model Coverage Determination Request” form to ask your plan for a coverage determination or exception. This form is available at www.cms.gov/MedPrescriptDrugApplGriev/13_Forms.asp, or call your plan and ask for a copy. Your plan must accept any written request for a coverage determination from you, your doctor, or your other prescriber.

How do I file a fast coverage determination?

You, your representative, your doctor, or other prescriber can call or write your plan to request that a fast decision be made within 24 hours of your request. You will get a fast decision if your plan determines, or your doctor or other prescriber tells your plan, that your life or health may be at risk waiting 72 hours for a decision. You won’t get a fast decision if you’ve already paid for and gotten the drug.

You can call your plan, write them a letter, or send them a completed “Model Coverage Determination Request” form to ask your plan for a fast coverage determination or exception. This form is available at www.cms.gov/MedPrescriptDrugApplGriev/13_Forms.asp, or call your plan and ask for a copy.

Should this situation occur to a medication that is NOT an excluded Medicare Part D medication, then we will provide you with a documentation of your Medicare Prescription Drug Coverage and Your Rights. This notice of your rights will provide you with what you can do to pursue this matter. Outcomes from following through with this process can lead to the plan allowing an exception, covering the medication, or at the very least, providing you with a written explanation specifying why your medication is not covered.

For your reference, this is a Table of the Part D Drugs/Part D Excluded Drugs as provided by the Center for Medicare and Medicaid Services for FREQUENTLY ASKED PRODUCTS (this is not an exhaustive list).

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References:

Centers for Medicare and Medicaid Services (2011). Medicare Appeals. pp39-49


Original Published:November 2011

Revised:November 2011