Key Takeaways

  • When you get your prescription drugs from a pharmacy, you may be told your Medicare Part D drug plan has been denied coverage.

  • You can appeal a drug coverage denial; it's important to understand the reason for denial first.

  • There are five steps you can take in a Part D appeal. Use these tips to have greater success.

What should you do if Medicare Part D plan denies coverage of a medication?

These tips were developed for us by the Medicare Rights Center, and explain the five levels of appeal rights you have regarding Part D coverage denials.

Medicare Part D covers outpatient prescription drugs. Each Part D plan has its own formulary, a list of  drugs that a plan covers. When you get your prescription drugs from a pharmacy, you may be told your drug has been denied coverage and receive a notice titled Medicare Prescription Drug Coverage and Your Rights.

The first step is to find out why you were denied coverage for the drug by contacting your Part D plan. There are many reasons for why a Part D plan may deny coverage for a prescription drug, but there are some more common reasons:

  • Prior authorization: you must get prior approval from the plan before it will cover a specific drug
  • Step therapy: the plan requires you try a different or less expensive drug first
  • Quantity limits: the plan only covers a certain amount of a drug over a certain period, such as 30 pills per month
  • Off-formulary: the drug is not on the plan's list of covered drugs

Before you start the formal appeal process, you will need to send the plan an exception request or a request for a coverage determination. You should contact your plan for information on where to send it and what information is required. You may also want to ask your doctor for help with this.

The plan will give you a decision within 72 hours. If the exception request is approved, your drug will be covered. If not, you can proceed with a formal appeal.

Steps in the appeal process

If your exception request is denied, or the response to a coverage determination request is unfavorable, your plan should send you a Notice of Denial of Medicare Prescription Drug Coverage. Then you can begin your appeal.

  1. Appeal with the plan: You have 60 days from the date listed on the notice to file an appeal with the plan. You should follow the directions on the notice. The plan should issue a decision within seven days. If the plan approves the appeal, your drug will be covered. If it is denied, you can proceed to Step 2.
  2. Appeal with the Independent Review Entity (IRE): You must send their appeal to the IRE within 60 days of the date listed on the plan denial. The IRE should issue a decision within 7 days. If the IRE approves the  appeal, your drug will be covered. If not, you can proceed to Step 3.
  3. Appeal with the Office of Medicare Hearings and Appeals (OMHA): If the appeal is denied and the drug is worth at least $170 in 2020, you can choose to appeal to the OMHA level. You must submit the appeal within 60 days of the date on your IRE denial letter. OMHA should issue a decision within 90 days. If the appeal to the OMHA level is successful, your drug will be covered. If not, you can proceed to Step 4.
  4. Appeal with the Council: The appeal to the Council must be sent within 60 days of the date on your OMHA level denial letter. The Council should issue a decision within 90 days. If the appeal to the Council is successful, your drug will be covered. If not, you may be able to proceed to Step 5.
  5. Appeal with the Federal District Court: If the appeal is denied and your drug is worth at least $1,670 in 2020, you can appeal to the Federal District Court within 60 days of the date on your Council denial letter. There is no timeframe for the Federal District Court to issue a decision about the appeal. If the appeal is successful, your drug will be covered. You may want to consult an attorney to decide whether it makes sense to appeal in District Court.

Tips for a successful appeal

  • Ask your doctor to write a letter of support addressing the plan's reasons for not covering the needed drug.
    • Doctors can confirm medical necessity and may be able to work closely with you through the appeals process.
  • Contact a lawyer or legal services organization if you need help with steps after the IRE-but it is not required.
  • Keep records of the conversations you have with your plan, as well as any documents you receive from your plan, your provider, or entities at higher levels of the appeals process.
  • Be persistent. Each level of an appeal is an independent decision, therefore an appeal denied at a lower level may be approved at higher levels without any new or additional information.