If you commonly use prescription medications, you most likely have a Medicare Part D Prescription Drug Plan. These plans are designed specifically to provide medication coverage for Original Medicare recipients. Or, you may also have a Medicare Advantage plan that includes prescription drug coverage. Each of these plans can differ in the specific medications that are covered, and the prices of those drugs. Some prescriptions can be extremely expensive, especially if their cost must be covered fully out of pocket. If your Medicare drug plan does deny coverage for a specific medication that you need, there is an appeals process you can go through to attempt to obtain coverage.
Check to see if Medicare generally covers the medication
Your first step should be to check if the drug is covered under another part of Medicare. If a specific drug is not covered under Part D, you should first establish whether it is covered under Medicare Part A or Part B. Some drugs, such as vaccines, cancer drugs, and infusion or injectable drugs are not covered under Medicare Prescription Drug Plans but, instead, are covered under another part of Medicare.
There are some drugs that Medicare does not provide coverage for under any circumstance. These drugs can include over-the-counter drugs or medications that have not obtained approval from the Food and Drug Administration. Other drugs can include those that are only sold outside of the United States or that do not have any medically-accepted purpose.
There are some drugs that are only covered by Medicare in certain situations on a case-by-case basis. These medications can be those used for weight loss or weight gain, cold or cough symptoms, fertility, hair growth, cosmetic reasons, or sexual dysfunction.
In some cases, the generic version of a drug may be covered by Medicare, while the brand-name one drug may not be. If this may be the case, your physician can determine if there is a potential alternative medication that you can use that will be covered by your Medicare insurance. Changing the medication to an already approved option would prevent the need for further action and appeal.
Requesting a formulary exception
Each Medicare prescription drug plan has a formulary, which is a list of covered medications. This list is updated regularly.If your doctor can’t suggest a different medication that is covered, you can file a request for a formulary exception with your drug plan. This can occur when you and your physician believe that the current non-covered medication provides the best option to treat your condition.
If you file for an exception, Medicare may grant your appeal if it’s determined that the medication is medically necessary for your health. To file, you will need a written statement from your physician supporting your case. Once the required documentation is filed, you will receive an answer within 72 hours of Medicare’s decision. If taking the medication is critical and 72 hours of waiting could place your health in jeopardy, you can request an expedited decision, which will provide an answer in 24 hours.
Filing an appeal
If your exception proposal is denied, the next step is to enter the appeals process, which consists of five levels. The first of these is a request for re-determination, which requests another decision for the formulary exception. If this is denied, you can then request review by an Independent Review Entity. For a further denial, you can request review by the Office of Medicare Hearings and Appeals, then by the Medicare Appeals Council, and then progress to the fifth level of appeals by requesting judicial review by a federal district court. You have the right to continue to progress to the next level of appeals as long as you meet the Medicare criteria.
If you are eligible for an enrollment period, you can research other options and find an alternative Part D or Prescription Drug Plan that may provide coverage for the medication in question. Be sure that you confirm that the specific medication and dosage is covered prior to switching plans.