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Senior Citizens Have an Appeal Process When Medicare Drug Plan Fails to Cover Needed Drugs
Senior Journal
April 13, 2009
Many senior citizens that receive their drug coverage from a Medicare private drug plan (Part D) have run into difficulty obtaining insurance coverage for the drug they need. This report from the Medicare Interactive newsletter by the Medicare Rights Center advises seniors on how to handle the challenge and explains the appeal process.
The drug that you need may not be easily accessible through your plan for one of the following reasons:.
● the drug may not be on your plan’s formulary (the list of prescription drugs that your plan will pay for either in part or in full); or
● it may be on your plan’s formulary but with restrictions, such as prior authorization (you must get your plan's approval before it will pay for the drug) or
● step therapy (your doctor must show that you tried a less expensive medication before your plan will cover a more expensive one), or
● in some cases you may have difficulty getting the dosage or amount of a medication your doctor has prescribed if the drug is subject to quantity/dosage limits.
In these and a few other cases, you will have to make an appeal to your drug plan to cover the drugs that you need. To file an appeal with your drug plan, follow these steps:
Step 1: Request an exception to the plan’s formulary.
To ask for an exception, get a written supporting statement from your doctor certifying that the drug prescribed is medically necessary and that no other covered drug will work for you. Call your plan or look at your plan's web site or Evidence of Coverage booklet to find out where to fax or mail your request and your doctor's supporting letter and whether you need to submit any other forms. Send a copy of your doctor’s letter and any medical records that support your request, such as medical histories or lab reports, to your plan. The plan must decide within 72 hours of receiving your request (24 hours if it is an expedited appeal).
Step 2: If your plan denies your request for an exception, appeal!
Before you can begin the appeals process, you must have already asked for an exception and been officially denied in writing. A “no” at the pharmacy is not an official denial. If your exception request is denied, your plan should send you a written denial titled "Notice of Denial of Medicare Prescription Drug Coverage." The notice should clearly explain why the plan is denying coverage for your prescription. You have 60 days from the date on the "Notice of Denial" to submit your appeal. By appealing, you are asking for a redetermination from the plan.
● Send the same materials from Step 1 to your plan’s Appeals Department. Your doctor’s letter should address the reason given for the denial—this may require updating the original letter. For example, s/he should confirm that other medications on your plan’s formulary have not worked for you or why you require the prescribed dosage of the drug.
● If you have to pay for your drug out of pocket since your plan denied your exception request, be sure to submit receipts and request reimbursement from your plan in your appeal.
The plan must respond no later than seven calendar days from the date it received the request (72 hours if an expedited appeal). If you receive a denial at this level, move on to Step 3.
Step 3: Get an independent review from the Independent Review Entity (IRE).
Maximus Federal Services handles appeals
If your plan denies coverage again, get an independent review from the IRE, Maximus Federal Services, the private contractor that handles Medicare prescription drug appeals.
Appealing to Maximus is no more difficult or complicated than appealing to your plan. Appeal within 60 days of the date on the second "Notice of Denial" from your Medicare private drug plan.
Send all your documents - including any receipts for out-of-pocket expenses for the denied prescription - to the Independent Review Entity. Include your
10-digit Medicare number, date of birth and contact information on the appeal.
● If your plan raised new reasons for denying coverage for your prescription in its second denial notice, your doctor may want to update the letter of medical necessity to address those new reasons. Maximus must return a decision within seven days for standard appeals and 72 hours for expedited appeals.
● If your doctor submits this appeal on your behalf, you will need to appoint your doctor as your representative by signing an "Appointment of Representative" form (available at http://www.cms.hhs.gov/CMSForms/downloads/cms1696.pdf). Have your physician submit the form along with the letter of medical necessity. A signed "Appointment of Representative" form allows your doctor to represent you throughout the appeals process. A signed form also allows your doctor to represent you in any other Medicare prescription drug appeals over the course of the calendar year.
Other Steps: ALJ, MAC and Judicial Reviews
If you disagree with Maximus's decision, you can request an Administrative Law Judge (ALJ) hearing within 60 days of Maximus's decision if the annual cost of the drug meets the minimum amount that Medicare sets each year ($120 in 2009). Multiple appeals can be consolidated to meet this amount, and you can project the cost of the drug to include all refills you will need for the calendar year. Maximus has 90 days to respond to your appeal.
If you disagree with the ALJ's decision, you can appeal within 60 days of the date on the ALJ decision to the Medicare Appeals Council (MAC). The MAC can also review the ALJ decision on its own initiative. MAC decisions are due within 90 days.
If you disagree with the MAC's decision or if the MAC denied your request for appeal, and the annual cost of the drug meets the minimum amount ($1,220 in 2009), you can request review by a federal court.
For help with your appeal, call the Medicare Rights Center’s appeals hotline at 888-466-9050.
To learn more about the appeals process, go to Medicare Interactive Counselor at www.medicareinteractive.org. Medicare Interactive Counselor is a resource provided by the Medicare Rights Center, the largest independent source of health care information and assistance in the United States for people with Medicare.
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