Medicare prescription drug coverage appeals

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 if you disagree with your plan's decision about whether to provide or pay for a drug.

What if my plan won't cover a drug I think I need?

You have the right to do all of these (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. You can ask:
    • Whether the plan has special coverage rules
    • Whether there are generic, over-the-counter, or less expensive brand-name drugs that could work 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 [Glossary] , including these:
    • Whether a certain drug is covered
    • Whether you have met the requirements to get a requested drug
    • How much you pay for a drug
    • 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 .
    • You or your prescriber believes that a coverage rule (like prior authorization) should be waived.
    • 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 disagree with your plan’s “at-risk determination” under a drug management program that limits your access to coverage for frequently abused drugs.

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.

Note

Your doctor or other prescriber (for prescription drug appeals) 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. The appeals process has 5 levels. If you disagree with the decision made at any level of the process, you can generally go to the next level. At each level, you'll get instructions in the decision letter on how to move to the next level of appeal.