Your plan will send you information that explains your rights called an "Evidence of Coverage" (EOC). Call your plan if you have questions about your EOC. You have the right to ask your plan to provide or pay for a drug you think should be covered, provided, or continued. You have the right to request an appeal to resolve differences with your plan.
What if my plan won't cover a drug I think I need?
You have the right to do all of the following (even before you buy a certain drug):
- Talk to your prescriber—your doctor or other health care provider who's legally allowed to write prescriptions. Ask whether the plan has special coverage rules. You can also ask your prescriber if there are generic, over-the-counter or less expensive brand name drugs that could work just as well as the ones you're taking now.
- Get a written explanation (called a coverage determination) from your Medicare drug plan. A coverage determination is the first decision made by your Medicare drug plan (not the pharmacy) about your benefits, including whether a certain drug is covered, whether you have met the requirements to get a requested drug, how much you pay for a drug, and whether to make an exception to a plan rule when you request it.
- Ask for an exception if you or your prescriber believes you need a drug that isn't on your plan's formulary.
- Ask for an exception if you or your prescriber believes that a coverage rule (such as prior authorization) should be waived.
- Ask for an exception if you think you should pay less for a higher tier (more expensive) drug because you or your prescriber believes you can't take any of the lower tier (less expensive) drugs for the same condition.
You or your prescriber must contact your plan to ask for a coverage determination or an exception. If your network pharmacy can't fill a prescription, the pharmacist will show you a notice that explains how to contact your Medicare drug plan so you can make your request. If the pharmacist doesn't show you this notice, ask to see it.
You or your prescriber may make a standard request by phone or in writing, if you're asking for prescription drug benefits you haven't gotten yet. If you're asking to get paid back for prescription drugs you already bought, you or your prescriber must make the standard request in writing. You can call your plan, write them a letter, or send them a completed "Model Coverage Determination Request" form to ask your plan for a coverage determination or exception. Once your plan has gotten your standard request, it has 72 hours to notify you of its decision.
You or your prescriber can call or write your plan for an expedited (fast) request. Your request will be expedited if you haven't received the prescription and your plan determines, or your prescriber tells your plan, that waiting for a standard decision may seriously jeopardize your life, health, or ability to regain maximum function. Once your plan has gotten your expedited request, it has 24 hours to notify you of its decision.
If you're requesting an exception, your prescriber must provide a statement explaining the medical reason why the exception should be approved.
Your doctor or other prescriber can request this level of appeal for you, and you don’t need to appoint them as your representative.
Your Medicare drug plan will send you a written decision. If you disagree with this decision, you have the right to appeal.