What to do if Medicare denies prescription drug coverage

Receiving a refusal at the pharmacy for a medication you need can be a stressful experience. When Medicare refuses to cover a prescription, some might worry that they won’t be able to pay for the drug out of pocket. Others might also need the treatment immediately and fear that the lack of coverage will negatively affect their health.

Medicare may initially refuse to cover prescriptions for a variety of reasons, such as when your plan generally does not include your drugs on its list of covered drugs. However, you have the right to ask your plan to cover the treatment you need and to request an appeal if you disagree with your plan’s decision not to include your medication.

Steps to take following a refusal of an order

If your plan doesn’t cover a drug, let the healthcare professional who prescribed it know. Your prescriber may be able to find another medication included in your plan. For example, you may be able to switch from a brand name drug to a generic drug.

In the event that there is no viable replacement for the drug or you are not satisfied, you have the right to ask Medicare for an exception so that your plan covers the drug. Your prescriber can also advocate for you and contact Medicare on your behalf.

As a Medicare beneficiary, you have the right to receive a coverage decision outlining the reasons for the denial, and you have the right to request an exception.

When requesting an exception, it is helpful to have the support of your doctor or the person who prescribed the medication for you. For example, your doctor can help your case by writing a letter explaining why you need the medicine.

If, on your request, Medicare denies drug coverage, you may appeal or appoint a trusted healthcare professional as your representative to appeal on your behalf.

There are five levels in the appeal process. To begin this process, you can ask Medicare to review your plan and then ask an independent review entity to review it.

The Office of Medicare Hearings and Appeals (OMHA) reviews coverage decisions for drugs that meet a minimum value, and the Medicare Appeals Council reviews OMHA judgments. For 2022, the drug must cost at least $180 for an OMHA evaluation. To reach this amount, callers can combine the values ​​of several drugs.

Where denial of coverage persists, beneficiaries may appeal to federal district court. To reach the federal district court, the minimum value of salaries must be $1,760 in 2022.

What to do if you need the medicine right away

Those in urgent need of medication can request an expedited appeal and receive a decision on the exception request within 72 hours. Medicare’s inability to cover your treatment must jeopardize your life, health, or ability to return to maximum function.

For help appealing a denial of coverage, talk to an attorney who understands the Medicare appeals process.

Last modification: 11/01/2022

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