Challenge a Non-Covered Medication Charge?

If the doctor prescribes a drug that is not on the PDP’s formulary as a covered drug and the doctor believes that other alternatives are not appropriate for the care of the beneficiary, a “coverage determination request” for an exception can be made by the beneficiary and/or the doctor.

The coverage determination request should be made directly to the Part D Plan in a way that is instructed by that plan. Each plan has a customer service help desk that will provide specific instructions as to the way in which the information should be submitted.

After submitting evidence to the plan in support of the exception request, the plan must notify the beneficiary of its decision within 72 hours or within 24 hours if an “expedited review” is requested due to an urgent health condition.

The most common reasons for requesting an exception include:

• The member’s drug has been removed from the formulary after being previously covered
• The doctor prescribes a medically necessary drug that isn’t on the plan’s formulary
• The member’s drug is moved from a preferred status to non-preferred status with a higher co-payment requirement; or
• The doctor prescribes a drug that is subject to a formulary restriction such as quantity limits, step therapy or a prior authorization, but is unable to modify treatment in accordance with the restriction.

IF the PDP denies a coverage determination request, the member may file an appeal for a “coverage re-determination”. The PDP will notify the member of the initial denial with a “Notice of Denial of Medicare Prescription Drug Coverage” letter and will provide instructions for requesting an appeal.

If the PDP denies the appeal, a second level appeal called a reconsideration can be made. This reconsideration request will be made to an independent review entity. The PDP’s denial letter will provide a model Request for Reconsideration form that should be read carefully.

Beneficiary rights are very important and there are 5 levels of appeal. At each step, the denial notification will provide instructions how to proceed to the next level. They are:

• REDETERMINATION (first level)
• RECONSIDERATION (second level)
• ADMINISTRATIVE LAW JUDGE (third level)
• MEDICARE APPEALS COUNCIL (fourth level)
• and U.S. DISTRICT COURT APPEAL (fifth level)