Did you know there is a process in Medicare Part D to appeal a coverage decision made by your plan about a medicine you need? Meaning, if a beneficiary is told at the pharmacy counter that his or her medicine isn’t covered or if they disagree with the cost-sharing amount, that isn’t the end of the line.
Every Part D beneficiary is entitled to request a written explanation from their plan about whether a certain medicine is covered, what the requirements are to receive a treatment and how much it will cost. This is called a coverage determination. If you or your doctor disagree with a coverage determination made by your plan, you have the right to appeal this decision.
The appeals process exists to help ensure beneficiaries don’t stop taking needed medicines and can avoid more serious and costly health outcomes. Here is what you should know about appealing a coverage determination:
- Once you have requested and received a formal coverage determination from your plan, you can then file an appeal. Your plan is required to notify you of its decision within 7 days for a regular appeal and 72 hours for an expedited appeal.
- If you disagree with this decision, you can ask your plan to reconsider (known as a redetermination). If you still disagree with your plan’s decision following redetermination, you can request an independent review of your case (known as reconsideration) and your plan will provide additional information on this.
For more information on appeals, check out these resources:
- Medicare Rights Center’s interactive web-based resources
- To get help filing your appeal, contact your local State Health Insurance Assistance Program (SHIP)
- For more details on what an appeal is and how to proceed should you decide to file one, Medicare.gov has details
- If your Part D plan provider doesn’t respond to your request for an appeal, you can file a complaint with Medicare by calling 1-800-MEDICARE
As we noted last week’s Medicare Monday blog, an individual’s ability to get access and adhere to their prescription medicine regimen can help beneficiaries with a number of different conditions achieve better health outcomes and also save money. To learn more, check out the resources above, and we encourage you to stay-tuned in the coming weeks for more on how the Part D program helps beneficiaries get the medicines they need.
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Allyson Funk Ally is a former senior director of public affairs at PhRMA focused on advocacy issues for the biopharmaceutical industry. Her expertise includes Medicare, Medicaid, 340B, health reform and more. Prior to PhRMA, her experience includes leading health communications for a large membership organization, supporting public affairs clients and working for the governor of Louisiana.