Medicare Part D recipients can contest their drug plans’ refusal to admit or cover a drug they believe they need through its formulary by requesting prescription drug coverage determinations or by filing appeals and complaints.

Whether they’ve joined Original Medicare, Medicare Cost plans, some Medicare Private Fee-for-Service plans and Medicare Medical Savings Account (MSA) plans, Part D participants can use any of three methods of challenging their programs’ failure to cover medication they wish to take.

Some of the reasons for the challenges include requiring permission to do so, charging too much for a less-favored drug, demanding the trial of another drug before they are able to obtain the desired one and limiting the number of pills or dosages needed for a drug.

Beneficiaries have two ways to obtain Medicare drug coverage.

First, they can sign up for Medicare Prescription Drug plans Part D (PDPs) as added to Original Medicare, some Medicare Cost plans, some Medicare Private Fee-for-Service (PFFS) plans, and Medicare Medical Savings Account (MSA) plans.

Secondly, they can enroll in Medicare Advantage plans that function like home maintenance organizations, more commonly known as HMOs, or preferred provider organizations, also known as PPOs.

Medicare doesn’t cover all prescriptions as each drug plan has its own list of medications, also known as a formulary, which include generic and brand-name drugs.

Even if a drug is on a plan’s formulary, special rules may abound for filing for a prescription. A Medicare beneficiary might have to obtain consent from the drug plan to use the medication before it is covered.

The plan may also ask beneficiaries to start on another drug before it will cover the medication prescribed for them. Additionally, the plan may restrict the number of pills or dosage.

During the year, the plan’s list can also be altered because medications change and new drugs and medical knowledge emerge. Beneficiaries are typically notified at least 60 days in advance of this change.

At times, beneficiaries may disagree with a coverage or payment determination made by their drug plans.

If a plan won’t cover a drug a beneficiary thinks he or she needs or that it will cover it at a greater expense than he or she believes is needed to pay, he or she may

seek a coverage deetrmination if the drug is on a formulary. A beneficiary can make the request before paying for the drug.

He or she can ask for a type of determination also known as an “exception” if the beneficiary believes the plan should cover the medication not on its list because:

  • Other treatment choices on the list are not safe and effective;
  • The plan requires permission;
  • The beneficiary believes the plan should lower the price on the drug because the other choices do not work;
  • The plan asks that he or she try another drug first, or;
  • The plan limits the number of pills or dosage for the drug.

Beneficiaries can also write a letter to make the request but they can also find a copy of a form by phoning their drug plans or by viewing it on the Centers for Medicare and Medicaid at http://www.cms.hhs.gov/MedPrescriptDrugApplGriev/13_Forms.asp.

Once a drug plan considers a beneficiary’s case and reaches a decision, it will send him or her a notice. If the beneficiary disagrees with the finding on his or her drug plan’s coverage determination or exception request, he or she can appeal the decision within 60 days in writing, which is also called a redetermination.

He or she can also appeal through a review by an independent review entity, also known as an IRE; request a hearing with an administrative law judge, by telephone, video-teleconference or in-person hearing; review by the Medicare Appeals Council, and a review by a federal court.

Beneficiaries can also file a complaint about their plan, which also called a grievance. They may begin the process for a number of reasons. They include the following:

  • The plan did not decide about a coverage determination in time;
  • The plan did not send a beneficiary’s case to IRE;
  • The plan did not grant a request for an expedited determination;
  • A beneficiary waited too long for a prescription;
  • A beneficiary finds the customer service hours unaccommodating;
  • A beneficiary receives irrelevant plan material by mail;
  • The plan did not send required notices, and;
  • The plan does not follow Medicare rules.

A beneficiary who file complaints or grievances must do so in 60 days of an event involving any of the aforementioned reasons by telephone or in writing. The plan is required to notify him or her of its decision within 30 days of its receipt of the complaint.

SOURCE: Centers for Medicare and Medicaid, http://www.cms.hhs.gov/MedPrescriptDrugApplGriev/13_Forms.asp.

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