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Appealing a Medicare Claim Decision

Why, when and how to challenge a denial of benefits

Filing an initial appeal if you have a Medicare Part D prescription drug plan

 

You have the right to receive a written explanation from your Medicare Part D plan about whether a certain drug is covered, whether you have met the requirements to receive that drug and how much you’ll pay for it.

The benefits booklet provided by your Part D insurer includes step-by-step instructions explaining what you can do if you have problems or complaints related to your drug coverage and costs.

If you believe or your doctor believes you need a medication that isn’t on your plan list, you can ask for a special exception. You also can ask to pay a reduced price for an expensive drug if the less expensive options don’t work for you and your condition.

Anytime you request a plan exception, your doctor, or a health care provider who is legally allowed to write prescriptions, must provide a statement explaining why you should be given an exception.

  • Requests for plan exceptions can be made by phone or in writing if you are asking for a prescription drug you haven’t yet received.

  • If you are asking to be reimbursed for the price of drugs you have already bought, you must make your request in writing. If your life or health could be at risk by having to wait for a medication approval from your plan, you or your doctor can request an expedited appeal by phone.

  • If you disagree with your Part D plan’s decision, you can file a formal appeal. The first level of appeal is to your plan, which is required to notify you of its decision within seven days for a regular appeal and 72 hours for an expedited appeal. If you disagree with this decision, you can ask for an independent review of your case. Your plan will explain the next level of appeal.

 

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