How to Appeal a Medicare Drug Decision

Medicare Prescription Drug Plans ordinarily require that doctors prescribe drugs according to a tiered system. This helps to cut costs by requiring doctors to try less expensive drugs first. If your doctor prescribes a drug contrary to the tiering system, you'll either have to make a higher copayment for that prescription or pay for the entire prescription yourself. However, in some circumstances, such as medical necessity, you can appeal an initial determination by your Medicare coverage provider. In total, there are five levels of appeal: request a redetermination, request a reconsideration, request a hearing with an administrative law judge, request review by the Medicare Appeals Council and request review by a federal court. If you have asked your coverage provider for an exception and been denied, you must follow the appeals in order. The first step is to request a redetermination.

Things You'll Need

• Medicare claim number

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Instructions

• 1

  Read the initial denial notice that was sent to you by your plan. This will tell you where to send a request for redetermination for your plan.

• 2

  Write a letter to your plan. You must include your name, address, Medicare claim number (found on your Medicare card), name of the prescription drug in question, reason for your appeal and your signature.

• 3

  Speak with your doctor. You or your doctor can request an expedited review if waiting for a standard review would place your life or health at risk. Your doctor can also provide a statement for the plan as to why the prescription drug is necessary and should be covered. Your doctor can also provide medical records that support your appeal.

• 4

  Send your letter and any supporting documentation provided by your doctor within 60 days of the date on the initial denial letter you received. Your plan will review the information and make a decision within seven days if you requested a standard review or 72 hours if an expedited review was requested.