When an exception is denied for a medication, many Medicare members don’t realize they can use the Medicare part D appeals process to have their request reconsidered. It’s very frustrating for members to have a medicine prescribe to them and be told it’s not covered under their Medicare part D plan. That is something that no Medicare member wants to hear but it does happen. When this happens, there are certain things in place that can help a member get the medication they need covered.
Before the Medicare part D appeals process starts, there are certain things that have to be done. One of the first things that Medicare part D members have to go through is a denial. This happens when they take a medication to their pharmacy to be filled and are told that it’s not covered. Once that happens, members have to call their Medicare part D insurance provider and ask why it was denied. After they have been told the medication isn’t covered under the formulary, members have a right to ask for a formulary or tier exception.
That is the beginning of a very important process. There is some paperwork that has to be submitted to the Medicare part D plan provider and their benefits manager but it is worth doing. Once the proper paperwork has been turned in, a determination can be made. For some members, the decision will immediately be in their favor. For others, their request will be denied. When the request is denied members have a right to use the Medicare part D appeals process.
What is the Medicare Part D Appeals Process?
The denial of an exception request is something that can make a lot of people angry and frustrated. While that is a normal reaction, there is something that can be done about it. Those that don’t know about the Medicare part D appeals process will ask their doctor to change their prescription but those that know will fight the determination.
The Medicare part D appeals process is a process that will ask the Medicare part D insurance provider to reconsider their decision. This process will take a little more paperwork from the member and their doctor but it’s something that can be very important to the member.
During the appeals process, there are 5 levels that can be taken. During any of the 5 levels of the appeals process, a member can be granted their medication exception. The 5 levels of appeals are:
1.Redetermination by the Medicare part D insurance plan provider
2.Reconsideration by the Independent Review Board
3.Hearing with an Administrative Law Judge
4.Review by the Medicare Appeals Council
5.Review by a Federal District Court
This is a process that seems intimidating but it’s something that has helped get many medications put on a formulary under different circumstances. One of the most appealed medications on the formulary in the past has been Viagra. Because Viagra has begun to be prescribed for different uses aside from erectile dysfunction, it has been successfully appealed and placed on the formulary for some members.
Medications are very important to people. While Medicare doesn’t cover every medication made, they want to help those that need specific medications. The Medicare part D appeals process is one way to help get a specific medication covered under someone’s part D plan.