Part D Drug Denials and Appeals: What To Do To Get the Coverage You Need
Navigating Medicare Part D prescription drug coverage can be confusing, especially when you encounter a denial for a medication you need. This guide will equip you with the knowledge and steps to troubleshoot denials and initiate appeals to ensure you receive the medications your doctor prescribes.
Understanding Why Your Drug Was Denied:
There are several reasons why your Part D plan might deny coverage for a specific drug:
Non-formulary: Your desired medication is not on your plan's list of covered drugs (formulary).
Step therapy: Your plan requires you to try a lower-cost medication first before approving a more expensive one.
Prior authorization: You need pre-approval from your plan before receiving the medication.
Quantity limits: Your plan limits the amount of medication you can receive within a specific timeframe.
What to Do After a Denial:
Contact Your Plan: Call your Part D plan provider to understand the specific reason for the denial. This may involve requesting an explanation of benefits (EOB) document.
Review the Denial Notice: Carefully examine the information on the notice you received from your pharmacy. It should explain the denial reason and outline your appeal rights.
Work With Your Doctor: Discuss the denial with your doctor. They may be able to provide information to support the medical necessity of the medication or suggest alternative options covered by your plan.
Appealing a Denial:
Request a Reconsideration: You or your doctor can file a formal request for reconsideration with your plan. This is typically the first step in the appeals process.
Gather Documentation: Supporting documentation like medical records or letters from your doctor explaining the need for the specific medication can strengthen your appeal.
Time Limits: There are strict deadlines for filing appeals. You have 60 days from the date listed on the notice to file an appeal with your plan. Your plan should issue a decision within seven days. If your plan denies your appeal, you have several other steps you can take. See https://www.ncoa.org/article/appealing-part-d-coverage-denial for more information.
Note: If you or your doctor believe your health could be seriously at risk waiting for a standard appeal decision, you can request an expedited exception. With your doctor's support, your plan must consider your request under a faster timeline.
