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What Is a Medicare Prescription Drug Coverage Exception or Appeal?

October 5, 2017

If you’re enrolled in a Medicare plan that includes prescription drug coverage, your doctor may occasionally prescribe a medication that’s not in your plan’s formulary.

Each Medicare Prescription Drug Plan has a formulary, which is a list of medications covered by that particular plan. Formularies may vary among plans, and they may change at any time. You will receive notice from your plan when necessary.

If you believe that your Medicare Prescription Drug Plan should cover a drug that’s been prescribed for you, then you have the right to request that your plan covers the prescription in question. Also, in cases where a specific medication is covered by your plan and then the plan announces that it will no longer cover it, you may submit a request for continued coverage.

You can always consult your doctor, physician, or other health-care provider on the matter. Anyone who legally writes prescriptions for your treatment can advise you with respect to your Medicare Prescription Drug Plan to see if your plan has special coverage rules. There may also be generic, over-the-counter, or alternative medications that your plan does cover that may be a sufficient stand-in for necessary treatment. Your health-care provider will know if this is the case and can offer recommendations accordingly.

You also have the right to request a written explanation (called a coverage determination) from your Medicare Prescription Drug Plan. This is a document from your Medicare Prescription Drug Plan that explains whether or not a specific medication is covered and if you have met the medical requirements to have the requested drug added to the plan’s formulary and how much you pay for it. The coverage determination also indicates whether they will make an exception to a plan rule when you request it.

Exceptions to Medicare Prescription Drug Plans

You or your doctor can request an exception to your Medicare Prescription Drug Plan if your health-care provider deems a drug necessary for your treatment. You may also request an exception if your doctor or physician thinks that your plan’s coverage rule should be waived.

Some Medicare Prescription Drug Plans have a coverage rule that asks you to prove that some prescriptions are medically necessary before they will be covered. If your plan has this rule, then some prescription drugs are likely going to require prior authorization before your plan will cover them. These may include:

  • Expensive medications
  • Brand name medications with an available generic that costs less
  • Prescription drugs used for cosmetic reasons
  • Medicines with age limits (like acne medications used most commonly by young adults)
  • Prescription drugs used to treat a non-life threatening medical condition (such as erectile dysfunction drugs)
  • Prescription drugs not normally covered through the company but that are said to be medically necessary

You can also ask for an exception if you believe that you should pay less for a higher-cost prescription drug because your doctor believes there is no suitable less expensive alternative.

How do you request an exception?

Exceptions can be filed by your doctor directly to your Medicare Prescription Drug Plan, either by phone or in writing, and they must provide a statement explaining the medical reason why the exception should be approved. You will receive a response back from the Medicare Prescription Drug Plan with its decision within 72 hours, and if you do not agree with the consensus, you are free to appeal it.

What is an appeal and how do you file one?

The appeal process has several steps, but the appeal must be filed within 60 days of receiving the plan’s initial decision. Your doctor or health-care provider can submit the appeal on your behalf, and he or she can request either a standard or fast redetermination. Fast redeterminations must be met as quickly as your health condition requires but no later than 72 hours if your life is in serious jeopardy as a result of this refusal of prescription coverage.

Your plan could still potentially deny coverage of the requested drug. In these cases, you can request a review by an Independent Review Entity (IRE). You or your doctor can once more request a standard or fast redetermination, depending on the severity of the situation. In these cases, a standard request can take up to seven days to receive a response while a fast redetermination response comes no later than 72 hours in cases where you or your doctor feel your life is endangered by a standard wait.

You may request a hearing before an Administrative Law Judge (ALJ) once your case has been heard by an IRE. An ALJ is a representative of your Medicare Prescription Drug Plan, but not the same person who previously denied your exception request. The ALJ listens to your testimony, either over the phone, by video teleconference, or in person, and makes a decision. To get an ALJ hearing, the amount of your case must meet a minimum dollar amount. For 2018, the required minimum amount is $160. To file a request for a hearing you may fill out the Request for Medicare Hearing by an Administrative Law Judge form and submit a written request to the Office of Medicare Hearings and Appeals (OMHA) Central Operations that includes:

  • Your name, address, and Medicare number. If you’ve appointed a representative, include your representative’s name and address.
  • The appeal number included on the QIC reconsideration notice, if any.
  • The dates of service for the items or services you’re appealing. See your Medicare Summary Notice (MSN) or reconsideration notice for this information.
  • An explanation of why you disagree with the reconsideration decision being appealed.
  • Any information that may help your case. If you can’t include this information with your request, include a statement explaining what you plan to submit and when you’ll submit it.

If coverage is still denied, then you can next submit a review request to the Medicare Appeals Council and they will examine the ALJ’s decision in your case. All of the information needed to do this is contained in the ALJ’s hearing decision. However, it’s worth noting that if you would like your doctor to continue acting as your representative throughout this appeal process, it is necessary at this point to submit an Appointment of Representative form to continue to do so.

The final step in the appeals process is to put your appeal before judicial review in federal district court. For this to happen, the amount of your case must meet or exceed an established dollar amount. In 2018, the minimum amount is $1,600. The Medicare Appeals Council letter will include instructions for how to get your case in front of a federal judge. If your doctor or other health-care provider is acting as a representative for you in this process, you must submit another Appointment of Representative form.

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