How to Appeal Medicare Part D prescription drug coverage denial

Posted by awhite
March 11, 2009

Note: This is the third part of a three-part post on Medicare appeals.

Medicare Part D appeals are similar to those for Medicare Advantage, but have some distinct differences. In this post, we’ll use Part D to cover both standalone Part D prescription plans and prescription plans that are part of a Medicare Advantage plan, often referred to as MADP. As with Medicare Advantage, Part D appeals are different from those of Medicare Part A/B in that you’re appealing to the independent company that provides your Medicare benefits. You’ll need to contact your provider and ask about the appeals process. Most have information on appeals on their websites, including official forms. Your initial appeal is with your provider. If you’ve read the previous posts, you’ll know that there are multiple levels of appeals available to you.

Again, as with other appeals, the first thing you have to do is decide whether you want to take on an appeal on your own. We recommend educating yourself about the process, AND getting help. Consider contacting a State Health Insurance Assistance Program (SHIP) counselor. They’re trained to help in Medicare issues. A friend, family member, or attorney can also be named as a representative using the Medicare Appointment of Representative form.

You should also talk to your doctor to determine if there is a different drug that you can take that is covered by your plan.

So, in what situations would you consider appealing to a Part D or MADP plan? Generally, Part D appeals stem from you wanting:

In order to start the appeal, you’ll need the written ‘coverage determination’ from your plan before you can start the appeals process.  Coverage determination simply means that your plan has said whether, or not, they’ll cover a particular medication. That should only take 72 hours, or 24 hours if an expedited request is made. Of course, only a negative determination will lead you to an appeal. You’ll need a doctor’s statement explaining the medical necessity of your prescription. According to Medical Rights Center, “Your doctor’s letter must assert that the prescribed drug is medically necessary and:

  1. Any drug on the formulary would not be as effective and/or would be harmful to you.
  2. All other drug or dosage alternatives on the plan’s formulary have been ineffective or caused harm, or based on sound clinical evidence and knowledge of the patient, are likely to be ineffective or cause harm.

While your plan must accept any written request and cannot require you to use a specific form, it is best to use the coverage determination request form provided by Medicare.

If someone other than the member is making the request, documentation identifying the individual’s authority to act on behalf of the member, such as a completed “Appointment of Representative” form must be included.

If the plan denies the request for reconsideration, you can appeal to the Independent Review Entity (IRE) for review. For Medicare Part D, Maximus Federal Services is the IRE. If the IRE didn’t rule in your favor, you still have three additional levels of appeal.

If you haven’t contacted a SHIP counselor, or another professional specializing in Medicare appeals, now is the time. As we’ve said before, why forego free help in the first place? If you want to understand the details of the Medicare Part D appeals process, check out this section of Medicare’s site.

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