If Your Medicare Part D (Prescription Drug Coverage) Claim Is Denied

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If you encounter issues with your Medicare Part D prescription drug plan, you have certain rights. These include the rights to request a coverage determination, request exceptions, file appeals, and file grievances. A Health Insurance Counseling & Advocacy Program (HICAP) counselor may be able to help you with these issues. Find your local HICAP office online.

In this section:

You may authorize someone else — a family member, friend, caregiver or doctor — to be your representative in an appeal or complaint.

Please also refer to your plan’s Evidence of Coverage booklet for more information on appeal rights and procedures. The Evidence of Coverage is mailed to current plan enrollees in September and to new enrollees when the plan becomes effective.

Note: Complaints/grievances are not part of the appeals process outlined below. They are intended for complaints about your Part D plan that don’t involve coverage or payment issues.

Coverage Determinations

If your pharmacist notifies you that your Medicare prescription drug plan:

  • Won’t cover a drug you think should be covered
  • Requires you to get prior approval for your drugs
  • Requires you to try another drug before it will pay for the drug first prescribed
  • Limits the quantity or dose of the drug prescribed
  • Will cover the drug prescribed, but only at a higher cost than you think you should pay

Then you have 2 options:

  1. Request a coverage determination from your plan, or
  2. Pay for the prescription and then request reimbursement through a coverage determination.

Note: if you experience any of the situations above and are not able to get your drugs, the pharmacy must give you a standardized written notice. The notice tells you how to contact your Part D plan and request a coverage determination.

You, your doctor, family member or other authorized representative (call your plan to learn how to authorize a representative) can call your plan or write a letter requesting that the plan cover the prescription you need.

Once the request is received, the plan has 24 or 72 hours to notify you of its decision, depending on the type of request made:

  • Expedited Request: The plan has 24 hours to respond to an expedited request for a coverage determination. Your doctor may request an expedited coverage determination if he/she feels your life or health will be in danger by waiting for a standard decision. The plan must automatically process an expedited request from a doctor.

    You may also make an expedited request without your doctor’s support, but the plan is not required to process it as expedited. It may deny the expedited request and process it as a standard request. Thus instead of responding within 24 hours, the plan may respond within 72 hours. If the plan denies your request to expedite a coverage determination, you may file a grievance or resubmit the expedited request with your doctor’s support.

    The plan must respond to an expedited request within 24 hours by telephone. It must also mail you a written expedited coverage determination letter within 3 days.

    If the plan does not respond to your expedited request within 24 hours, it must send your request to the Independent Review Entity (IRE) within the next 24 hours. Learn more.

  • Standard Request: The plan has 72 hours to respond to a standard request for coverage of a benefit that has not been received. For a request for reimbursement of a benefit already received, the plan has 14 days to respond.

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Exceptions

An exception is a type of coverage determination request that requires you to submit a supporting statement from your doctor explaining why you need the drug you are requesting.

You may request an exception from your Medicare prescription drug plan if:

  • You are taking a drug that has been removed from the plan’s formulary.
  • A non-formulary drug is prescribed and medically necessary.
  • The copayment for a drug you are taking increases and you cannot afford it.
  • You want the plan to cover a non-preferred drug at the preferred drug cost.

In general, an exception request must be granted if:

  1. The plan determines the medication is medically necessary; and
  2. The prescribing doctor determines at least 1 of the following to be true:
    • None of the drugs on the formulary would be as effective as the non-formulary drug.
    • Any other drug would have adverse effects.

Once an exception is granted, it remains in effect for the calendar/plan year, as long as your doctor continues the prescription. If you renew your enrollment in the same Medicare drug plan at the end of the year, you may be required to submit a new exception request.

If the drug plan denies coverage, it must notify you (and your doctor, if he/she made the exception request) in writing within 72 hours if you submitted a standard request, or within 24 hours if you submitted an expedited request. The notice must explain the reason for denial and how to continue the appeals process.

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Appeals

If the plan’s coverage determination is not in your favor, you can appeal the decision. When you join a Medicare prescription drug plan, you will receive information about the plan’s appeal procedures in the Evidence of Coverage booklet. Keep this information where you can find it in case you need it. You can also call your drug plan for instructions.

The 5 levels of appeal are described below:

Level 1: Redetermination by Plan

The first step in the appeals process is through your drug plan. You must request the appeal within 60 days of the coverage determination date (this timeframe can be extended if you show good cause why you filed late). You, your doctor or an authorized representative must file a written request unless your plan accepts phone requests.

Once your plan receives your request, it has 72 hours (expedited) or 7 days (standard) to notify you of its decision. Your request will be expedited if your plan determines or your doctor informs the plan that your life or health will be seriously jeopardized by waiting for a standard decision.

Level 2: Reconsideration by Independent Review Entity (IRE)

If the plan’s redetermination is not in your favor, you can request a reconsideration by an IRE. You must make a standard or expedited request within 60 days of the date of the redetermination decision. The request must be written and sent directly to the IRE.

Once the request is filed, the IRE has 72 hours (expedited) or 7 days (standard) to notify you of its decision. Your request will be expedited if the IRE determines or your doctor informs the IRE that your life or health will be seriously jeopardized by waiting for a standard decision.

The IRE is required to request your prescribing doctor’s opinion about the appeal, and must include a written account of the doctor’s input in the redetermination documentation.

Note: Your prescriber also can request an independent review on your behalf without having to complete an appointment of representative form. In this case, your prescriber must notify you about the IRE request, and the IRE will then notify the prescriber of its decision.

California’s IRE is MAXIMUS Federal Services. Learn more online.

Level 3: Hearing with an Administrative Law Judge (ALJ)

If the IRE’s reconsideration is not in your favor, you can request a hearing with an ALJ from the federal Department of Health and Human Services. You must request the hearing in writing within 60 days of the IRE decision.

You must send the request to the entity specified in the IRE’s reconsideration notice. To receive an ALJ hearing, the projected value of your denied coverage must meet a minimum dollar amount, which is $150 (in 2016).

You can meet the minimum dollar amount several ways:

  • Use the projected value of the drug(s) in question over the course of the year
  • Combine 2 or more of your appeals
  • Combine 2 or more appeals from several people in the same drug plan, if they all involve the same drug

Once the request is received, the ALJ generally has 90 days to make a decision, although this timeframe can be extended for several reasons, including submission of new evidence or request for an in-person hearing. Hearings are generally conducted by phone or videoconference.

Note: You should consider seeking legal advice before requesting an ALJ review.

Level 4: Review by the Medicare Appeals Council (MAC)

If the ALJ’s decision is not in your favor, you can request a review by the MAC. You must make a written request to the MAC within 60 days of the date of the ALJ’s decision notice. The MAC generally reviews evidence in the record, and no hearing is involved. The MAC has 90 days to make a standard decision or 10 days to make an expedited decision after receiving the request.

Note: You should consider seeking legal advice before requesting an MAC review.

Level 5: Review by a Federal Court

If the MAC’s decision is not in your favor, you can request a review by a federal district court. You must make a written request within 60 days of the date of the MAC decision notice and send your request to the entity specified in the notice. To receive a federal court review, the projected value of your denied coverage must meet a minimum dollar amount, which is $1,500 (in 2016).

Note: You should consider seeking legal advice before requesting a federal court review.

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Complaints/Grievances

If you have a complaint about your Medicare prescription drug plan that doesn’t involve coverage or payment for a covered drug, you have the right to file a grievance.

Complaints can come from dissatisfaction with any aspect of a drug plan’s operations, activities or behavior. For example, you might file a complaint if:

  • You have to wait too long for your prescriptions at the plan’s pharmacy.
  • The plan did not make a decision within the required timeframe.
  • The plan denied your request for an expedited coverage determination.
  • You have trouble reaching the plan’s customer service department.
  • The plan did not provide customer service in your preferred language

You should file your complaint orally or in writing within 60 days of the event in question. The plan must notify you of its decision within 30 days of receipt of the grievance, although this timeframe can be extended at your request, or if the plan can show that a delay would benefit you. An exception is if your complaint is about the plan denying your request for an expedited coverage determination. In this case, the plan must respond within 24 hours.

If the plan doesn’t resolve your complaint, call 1-800-MEDICARE.

Quality of care complaints concerning your Medicare prescription drug plan can also be filed with Livanta, California’s Quality Improvement Organization (QIO). Contact Livanta online or by phone at 1-877-588-1123 or 1-855-887-6668 (TDD for the hearing impaired).

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