How to Win a Medicare Part D Appeal

You've arrived at the pharmacy with your prescription refill in hand. You hand it over, and you're told that your Medicare Part D prescription plan won't cover your prescription. If you and your doctor have determined that this is the only prescription that will work for you, it's time to start the Medicare Part D appeals process. There is no way to guarantee that your plan will make a decision in your favor, but there are steps you can take to increase the odds that you will win your appeal.

Things You'll Need

• Contact information for your Part D plan
• Your plan's prescription formulary (available in paper or online)
• Contact information for your doctor
• Notepad
• Pen
• Phone
• Envelopes
• Money for postage
• Access to a copy machine
• "Medicare and You" handbook for current year (mailed to Medicare beneficiaries annually)
• Computer with Internet access (optional)
• Printer (optional)

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Instructions

• 1

  Look up your prescription in your plan's formulary. The formulary lists all prescriptions that are covered by your plan. There are also notes that indicate whether your prescription isn't covered by any Medicare plans, if you've tried other prescriptions that treat the same condition first (called step therapy) or if your doctor should have obtained prior authorization. If you are unclear, call your prescription plan for an explanation.

• 2

  Call or visit your doctor's office and explain that your prescription coverage was denied. Talk with your doctor about the information you obtained from the formulary. Determine with your doctor whether any other prescriptions that are covered will meet your needs. If so, obtain a new prescription and have that filled. If nothing else will work, ask your doctor for a written statement on letterhead explaining the medical necessity of your prescription.

• 3

  Complete the Medicare Part D Coverage Determination Request form and mail it, along with your doctor's statement, to the address indicated by your plan. Make copies of what you are mailing. Use certified mail. You can also write a letter but, according to the Medicare Rights Center, that may make your request less likely to be approved. Your plan must respond to your request within 72 hours of receiving it. If you do not receive a coverage determination from the plan within a week of mailing the request, call the plan to follow up, and keep notes of who you speak with. Then call Medicare at 1-800-Medicare to report your plan. If the coverage determination letter you receive says your prescription has been denied, then proceed to the next step.

• 4

  Write a letter requesting a coverage redetermination. Include the letter from your doctor. Ask your doctor for journal articles, medical records and any other information that indicates this prescription is the only effective one for your condition and that other prescriptions may be harmful. Make copies of what you're sending. Mail this information to your plan via certified mail. The plan must respond within seven days of receiving your letter. If your plan denies your request again, proceed to the next step.

• 5

  Write a letter requesting a reconsideration. This request goes to an independent entity that reviews all reconsideration requests. Include all materials previously submitted to your plan. Ask your doctor if there is any additional information you can include. Call your plan to obtain the address for where to send the reconsideration request, keeping notes on who you spoke to and when. Make copies of everything you are mailing and send via certified mail. The independent review committee has seven days to review and respond to your request. If they overturn your prescription plan's decision, then call your plan to ensure they've received the information and get your prescription filled. If your request is denied, then proceed to the next step.

• 6

  Write a letter to request a hearing with an administrative law judge. At this stage, also consider calling your local State Health Insurance Assistance program for help with continuing the appeals process. The number is in the back of your "Medicare and You" handbook. The response from the independent review company will include the address to send this request. There is no time limit for the administrative law judge to respond your request. If the judge denies your request, proceed to the next step.

• 7

  Write a letter requesting a review from the Medicare Appeals Committee. There is no time limit for response from the committee. If your request is denied, write a letter requesting a review by a federal court. The court's contact information will be in the denial letter from the Medicare Appeals Committee. This is the highest level of appeal, although, rarely, an appeal may be made to a higher court.