Medicare Part D Appeals Process
What is a Medicare Part D appeal?
Have you ever been denied coverage for a certain drug on your Part D drug plan?
Did you think there was nothing you could do about it? Think again.
The only way to succeed with a Part D appeal is to make sure that the prescribing doctor submits a clear statement of medical necessity that only the prescribed medication will work for you. Many times the Part D drug plan will require that you take a generic form of the medication, or a simular medication that is on their formulary. This may not be best for you and only your doctor can submit that request to the Part D Plan.
The first thing you need to get from your Part D Drug Plan is a request of written coverage determination. You need this written coverage determination before you can start the appeals process. Getting a “no” at the pharmacy is not considered a coverage determination. You must call or write to the Part D drug plan company and ask for this written document. You must also submit a doctor’s statement of medical necessity to the Part D plan. The more documentation your doctor submits, the stronger your case will be. If your doctor is too busy or unwilling to help, you might also try contacting the nurse or physician’s assistant for help.
If your Plan still continues not to approve coverage for you, you may need legal assistance. The Medicare Rights Center has volunteer lawyers ready to assist you. You can call their Appeals Hotline at 888-466-9050.
There is a very valuable website available to you with in-depth instructions on this matter and many others. www.medicarerights.org
We hope this information will be helpful to you.
