What do I do if my Medicare drug plan says no to my request that it pay for a drug? (How do I appeal?)

If you have formally asked your plan to pay for a drug, override a restriction, or move your drug to a lower cost tier (requested an “exception”), and your plan turns you down, you should appeal.

Before you can begin the appeals process, you must have already asked for an exception and been officially denied in writing. A “no” at the pharmacy is not an official denial.

The process for appealing is the same whether you are in a Medicare private health plan with drug coverage (MA-PD) or stand-alone private drug plan (PDP).

How to appeal your plan's decision

• Your plan should send you a written denial titled "Notice of Denial of Medicare Prescription Drug Coverage." The notice should clearly explain why the plan is denying coverage for your prescription and tell you where to send your appeal.
• You have 60 days from the date on the "Notice of Denial" to submit your appeal. (Under certain circumstances, you may be able to appeal after 60 days if you have "good cause"—for example, if you were in the hospital and therefore could not appeal earlier.) By appealing, you are asking for a "redetermination" from the plan.
• The plan must respond no later than seven calendar days from the date it received the request. If it is an emergency, you or your doctor can ask for an "expedited" redetermination. Your plan must respond to an expedited appeal within 72 clock hours.
• If you have to pay for your drug out of pocket since your plan denied your exception request, be sure to to submit receipts and request reimbursement from your plan in your appeal.
  If your doctor submits this appeal on your behalf, you will need to appoint your doctor as your representative by signing an "Appointment of Representative" form. Have your physician submit the form along with the letter of medical necessity.
  A signed "Appointment of Representative" form allows your doctor to represent you throughout the appeals process. A signed form also allows your doctor to represent you in any other Medicare prescription drug appeals over the course of the calendar year.
  Medicare Appeals Council (MAC) review.
  If you disagree with the ALJ's decision, you can appeal within 60 days of the date on the ALJ decision to the MAC. The MAC can also review the ALJ decision on its own initiative.