Exceptions, Appeals, and Complaints
Just like with most things in life, everything doesn’t always go smoothly. Here’s what to do when you’re faced with challenges about your Medicare drug coverage.
Exceptions
(What if my plan won’t pay for a drug I need?)
Even with careful shopping, you may not be able to find a drug plan with a formulary that includes all the drugs your doctor might prescribe or one with a low copayment. In either of these situations, there are two things you can do:
- Work with your doctor to find another drug in your plan’s formulary (possibly one with lower copay) that is as safe and as effective as the one you are taking.
- File a formulary exception. You, your doctor, your pharmacist, or your personal representative can file a formulary exception request. With the help of your doctor or pharmacist, you will need to explain why drugs on the plan’s formulary are not as effective or why the plan’s drugs would cause harmful side effects.
Review the information sent by your plan on how to file an exception. Your plan may have a special form that needs to be completed or you can use the model form (Adobe Acrobat required) available from Medicare. Take the form to your doctor to complete.
Once you file for an exception your plan has 72 hours to respond. The clock starts when your plan gets the doctor’s supporting statement. Doctors may request response in 24 hours if they think it is in their patient’s best medical interest.
Appeals
If your request for an exception is turned down, you have 60 days to appeal the decision by submitting a request, orally or in writing, for a redetermination. Your drug plan must review your appeal normally within 7 days. Your doctor can request an expedited review within 72 hours if it is medically necessary. You cannot get an expedited review if you have already purchased the drug and are seeking reimbursement.
Independent Review Entity
If your plan failed to act on your initial appeal within the allowed timeframe, it will automatically be sent to next level of appeal, the Independent Review Entity (IRE). Or, if your appeal for a redetermination is turned down, you can direct your appeal to an IRE. (The time limits are the same as with appeals.) The IRE is independent of your drug plan. It reviews your case by gathering information and talking to your doctor and other doctors. If you win, your drug plan will be ordered to provide the drug within 72 hours or reimburse you.
Helpful Tip:
If a formulary exception is granted, it is good for the remainder of the calendar year. To continue the same coverage in the next enrollment year, check with your plan to see if you need to request the exception again.
Additional Appeals
If the IRE turns you down, there are three more levels of appeal you can file. To file an appeal at the next two levels, Administrative Law Judge and Medicare Appeals Council, your drug must cost at least $100 (in 2006), but you are allowed to meet the cost requirement by adding up all the costs for this drug over a full year. You can also appeal more than one drug at a time. You have 60 days to file, but there is no time limit for the review. The last step in the appeals process is the federal court system. It is similar to the previous two levels except your drug must cost at least $1,050 (in 2006) over the year. These dollar amounts may change year to year.
Complaints
If you have a complaint about your drug plan that doesn’t involve coverage or payment for a drug covered by the drug plan, you have a right to file a grievance. You should file the grievance within 60 days of the event that led to your complaint.
Reasons for complaints might include:
- You have to wait too long for your prescriptions.
- Your plan’s customer service hours are not convenient.
- The pharmacy is charging more than you think you should have to pay.
- The plan doesn’t give you a decision about a coverage determination within the required timeframe – for example, it takes more than 72 hours to respond to your request for an exception to cover a drug not on the plan’s formulary.
Resolving your complaint:
- Start by talking to your drug plan sponsor. If the customer service representative cannot help you, ask to speak to that person’s supervisor or the manager on duty.
- If the plan doesn’t take care of your complaint, call Medicare at 1-800-633-4227 (TTY 1-877-486-2048).
