How do I apply for an exception?
You have the right to ask your plan to cover a drug it doesn’t normally cover, or to waive a restriction on a drug you take, for medical reasons. This process is called requesting an “exception” or a “coverage determination.” (Under a regulation that began in 2013, pharmacies should provide you with instructions on what to do if your Part D plan will not immediately cover your prescribed drug.)
To apply for an exception, call your plan to ask for its coverage determination form. You also need your doctor to provide a statement saying why the drug you’ve been prescribed is necessary for your medical condition and (in the case of step therapy restrictions) show that less expensive meds don’t work for you or (in the case of quantity limit restrictions) show that a lesser dosage or quantity is not effective for you. A form that your doctor can fill out to support your application can be obtained from your plan or downloaded from the Medicare website.
The plan must respond within 72 hours of receiving your request and your doctor’s supporting statement. (These are hours by the clock, not business hours.) If your doctor thinks that waiting this long would endanger your health, you can ask for an “expedited decision,” which the plan must respond to within 24 hours.
If the plan grants your request, the exception will remain valid until the end of the year in most cases. (In the case of prior authorization, however, the plan may require repeat requests more frequently.) If the plan denies your request, it must tell you how to pursue it to a higher level of appeal.
What can I do if my plan denies my request for an exception?
You have the right to appeal its decision. If necessary, you can pursue your case through up to five levels of appeal:
- Redetermination — asking the plan to reconsider its denial.
- Reconsideration — asking an Independent Review Entity to review a redetermination denial.
- Administrative Law Judge hearing — asking an ALJ to review an unfavorable decision by the IRE.
- Medicare Appeals Council review — asking the MAC to review an unfavorable decision by the ALJ.
- Federal court hearing — asking a court to review an unfavorable decision by the MAC.
If your claim is denied at any level of appeal, you’ll receive instructions on how to proceed to the next level and the required time frames for requesting a review.
Anyone can help you make an appea l — a relative, friend, consumer advocate or lawyer — and, if you want, any of them can also formally represent you by preparing and presenting your case. At the higher appeal levels (Medicare Appeals Council or federal court) you’d need a lawyer familiar with the finer points of Medicare law. To find lawyers or consumer advocates who can give free or low-cost legal advice and representation, call your state health insurance assistance program (SHIP) for information on services in your area.
What about drugs that are covered by Medicare Part B?
Medicare Part B generally continues to pay for drugs it covered before Part D began — usually those that are administered at a hospital or doctor’s office. In some cases, the same drugs are covered by either Part B or Part D according to different circumstances. In this case, your Part D plan may contact you or your doctor to verify the circumstances in order to decide whether payment should be made by Part B or D.