When your Part D plan will not pay for your drug, you should receive a notice at the pharmacy titled Medicare Prescription Drug Coverage and Your Rights. This notice provides instructions on filing an exception request with your plan. Note that even though your plan will not pay for the medication, this initial notice is not a formal denial.
Call your plan to find out the reason it is not covering your drug. If your plan made an error, they should correct it. If not, there are a few common reasons a plan may deny payment:
- Prior authorization: you must get prior approval from the plan before it will cover a specific drug
- Step therapy: your plan requires you try a different or less expensive drug first
- Quantity limits: your plan only covers a certain amount of a drug over a certain period of time, such as 30 pills per month
- Off-formulary: the drug is not on your plan’s list of covered drugs
If your plan denied your drug for one of these reasons, ask your doctor to write a letter of support to send to your plan requesting an exception to the plan’s rules. This letter should explain why you need the drug and, if possible, how other medications to treat the same condition are dangerous or less effective for you. You should get a decision from the plan within 72 hours. If you need your drug immediately because your health could be seriously harmed by waiting the standard timeline, you or your doctor can request an expedited decision, and you should receive this decision from your plan within 24 hours.
If your plan approves your exception request, your drug should be covered until the end of the current calendar year. If your exception request is denied, you can choose to appeal.
For more information on the Medicare Prescription Drug Coverage and Your Rights notice, please call your plan or 1-800-MEDICARE.