Q. My Medicare Part D drug plan just denied coverage for my medication. Can I appeal its decision?

A. Yes. If your Medicare drug plan denies coverage for a drug you need, you don’t have to simply accept it. There are steps you can take to appeal the decision.

Background:  The insurers offering Medicare drug plans choose the medicines — both brand-name and generic — that they will include in their plan’s “formulary,” the roster of drugs the plan covers. This can change from year-to-year. If a drug you need is not in the plan’s formulary or has been dropped from the formulary, the plan can deny coverage. Also, plans may charge more for a drug than you think is fair, or may deny coverage if it believes you do not need that particular drug. If any of these things happen, you can appeal the decision.

Before you can start the formal appeals process, you must file an Exception Request with your plan. This usually will involve a statement from your doctor explaining your need for the drug. The plan must then respond within 72 hours, or within 24 hours if your doctor explains that you need an expedited decision for health reasons. If your exception is denied, the plan will send you a written denial-of-coverage notice, and the five-step appeals process then begins.

  1. The first step is to ask the insurer for an internal Redetermination, following the instructions it provides you. Submit the statement from your doctor explaining why you need the drug, along with supporting medical records. If your doctor informs the plan that you need an expedited decision for health reasons, the plan must respond within 72 hours. Otherwise, it must reply within seven days.
  2. If the redetermination is not satisfactory, you then have 60 days to request Reconsideration by an independent board. Again, follow the instructions on the written redetermination notice you received from your plan. An Independent Review Entity (IRE)will review your case and issue a decision either an expedited decision within 72 hours, or a standard decision within seven days. If you receive an adverse decision, you can continue the appeal process.
  3. The third level of appeal is to make a timely request for hearing before an Administrative Law Judge (ALJ), which will allow you to present your case either over the phone or in person. To request a hearing the amount in controversy must be at least $160 (in 2018). Your request for a hearing must be sent in writing to the Office of Medicare Hearings and Appeals (OMHA).[Phone: 1- 844-419-3358]. Following hearing, the ALJ will issue an expedited decision within 10 days or a standard decision within 90 days.
  4. If the ALJ rules against you, the next step is to request review within 60 days by the Medicare Appeals Council. [Phone: 1-202-565-0100]. The appeals council will issue an expedited decision in 10 days, or a standard decision within 90 days.
  5. The final step is to seek judicial review in Federal District Court within 60 days of the adverse decision by the Appeals Council. To qualify for judicial review, the amount in controversy must be at least $1,600 (in 2018), and you may need to engage an attorney for help.

For more information, visit www.Medicare.Gov and go to “Claims and Appeals”,  and www.HHS.Gov and go to “Appeals Process”].