Medicare Part D: Appeals
Before you can begin the appeals process for coverage about a drug that is not covered under your Medicare Part D plan, you must receive a denial in writing.
Once this denial is received, either you or your doctor can call and ask the plan to cover the drug. This is known as an exception request. An exception request can be done over the phone or in writing. If the drug is needed on an emergency basis, an expedited review can be requested. With an expedited review, you must receive the answer within 24 hours of the request. (For an expedited review of an appeal, the company has 72 hours.)
The process for appealing is the same whether you are in a Medicare Advantage Plan or a stand alone private drug plan.
- Your doctor will need to fill out a Medicare form or write a letter which (1) explains why the drug is a "Medical necessity" for you and (2) asks that the drug be covered . (Ask your doctor if he or she will do the appeal for you. Many will.)
- The plan is supposed to respond within 72 hours after receiving the doctor's statement.
- If the plan denies the request, you can ask for an exception. This must be done within 60 days of the date on the letter which denies the exception. Again, a letter is needed from the doctor stating the the drug is medically necessary. Plans have 7 days from the date of the receipt to respond.
- If the appeal is denied, you can continue through the plan's remaining appeal process.
As a general matter, approval only lasts until the end of the calendar year. It is possible to ask for an indefinite exception (also known as grandfathering.)
If you need help with an appeal: check with your doctor's office to see if they will do the appeal for you. If not, ask a relative, friend or social worker to help. You can also engage a professional to help. For information, click here.)