Your Guide to Medicare Part D

Take Action: Excpetions, Grievances and Appeals

Prescription drug plans have procedures in place for contesting a plan’s policy if you cannot get coverage for a drug that you need. There are several reasons you may need to do this; for example, perhaps the drug you need is not included on the formulary, or the drug has a high cost-sharing level and is the only drug you can take.

If your pharmacist tells you the medication you have been prescribed is not covered by your plan and therefore cannot be filled (unless you are willing to pay the entire cost), the first step you must take is to contact your prescription drug plan and request a coverage determination.  This is a formal decision by your plan as to whether it will provide coverage for that drug.

When to File for an Exception

You may consider filing for an exception for the following reasons:

• If the drug you need to take is not included on your plan’s formulary and no other drug on the formulary meets your specific need
• If your Part D plan changed the drugs listed on its formulary
• If you want the drug to be covered at the lowest level of cost sharing

There may be additional situations other than these in which you may need to request an exception.

To get started, either you, your appointed representative (someone you authorize to act on your behalf or someone authorized by state law to act on your behalf), or your doctor must contact your plan and tell them that you wish to request an exception. Provide the plan with the reason you need the exception—what harm could result if you did not get the prescribed drug and had to take a generic or substitute drug in its place. Then note what you want the plan to do while you await its decision, for example, providing you with a temporary supply of the drug until your doctor provides clinical justification for your prescription.

It is important that your prescribing doctor explain why you must receive the specific treatment in question and note that less expensive drugs have not worked, are not appropriate, or are not safe for you in this case, listing the reason(s).

Exceptions are granted if the plan finds that your treatment is “medically necessary.” You will get a response within 72 hours, or 24 hours in case of an emergency. Forms to file an exception can be found at www.cms.hhs.gov/center/provider.asp under “Part D Tools for Health Care Professionals,” along with contacts for each plan and a wealth of other information.

If your exception is granted, it will remain effective at least until the end of the year, if you continue to take the medication and if it continues to be effective. At that point, your plan may extend the exception into the next year, or you may have to go through the exception process again. Check with your plan so that you know if you have to get the exception granted again. Start early so that your treatment runs smoothly.

The Appeals Process

If your exception is denied, you or your appointed representative (but not your doctor) is eligible to file an appeal, a request for further review to determine if a drug should be covered. In an appeal, you are asking the plan to reconsider its decision.

The first step in the appeals process is to request a redetermination of a coverage determination. Write to your plan asking for a redetermination of its decision not to cover a drug or not to reduce the cost-sharing level of a drug. Supply the following information:

• The name of the drug
• The reason the plan provided for its denial
• The reason that justifies your appeal

(You may be permitted to present your case orally, but having it in writing is to your benefit. Remember to keep a copy of all your correspondence and log any phone conversations, along with detailed notes.) You must send your request for a redetermination within 60 days of the date you were denied coverage or a cost-share reduction for a drug, although you may be able to request a redetermination after more than 60 days.

Filing Grievances

When you have a complaint about something other than drug coverage or costs, such as a continual busy line to customer service, you can file a grievance. To file a grievance, call toll-free 800-MEDICARE or TTD: 877-486-2048 or contact your plan’s customer service phone number for instructions.

Plan Response Time for Exceptions, Appeals, and Grievances

According to law, Part D drug plans must respond to exceptions, appeals, and grievances within a certain specified period of time.

Exceptions: Part D prescription drug plans have only 72 hours to make a coverage determination, faster if the decision is needed to protect your life or health. In emergencies, or in cases where a delay in coverage could cause harm to your health, the plan must respond within 24 hours.

Appeals: Plans have 7 days to respond to a standard appeal but must respond more quickly if your health is in jeopardy. Plans must respond within 24 hours to an expedited appeal.

Grievances: You have 60 days after an event or incident to file a grievance. If the grievance involves a plan’s failure to determine coverage for a drug, the plan must respond within 24 hours. If the grievance involves a different type of problem, plans have 30 days to respond. In some cases, the 30-day period may be extended by up to 14 days, but notification of that extension must be in writing.

If Your Appeal Is Denied

If your appeal is denied, you may move on to the next step, which includes review by an Administrative Law Judge (ALJ), who is independent of the Part D plan. To qualify for this type of appeal, the amount of money involved in the denied drug coverage or shared-cost level must be at least $110 in 2006, an amount that will be adjusted each year.

If the ALJ does not find in your favor, and the amount in dispute is at least $1,090 in 2006 (an amount that will be adjusted annually), you may move on to the federal court system, a process that may take months or years, and a considerable financial investment if you do not locate an attorney who will work for free, or pro bono.