If your Part D plan says that it won’t cover a prescription that you need, you can appeal that decision.
Step 1: The first step in an appeal is to ask for a “coverage determination” from your plan. This is the written explanation of what the Part D plan will cover. The standard time frame to get this information is 72 hours. You can ask to get it within 24 hours if you have an emergency need such as needing essential medication.
Step 2: The second step in the Part D appeal process is to ask for a “Standard Redetermination.” The standard time frame is seven days for benefits. You can ask for it to be “expedited” (faster) and get it in 72 hours.
There are more appeal levels in the Part D process. See this flow chart for an overview of the entire appeal process.
Visit the links below for more information on getting your prescriptions covered by your Part D plan.
- Learn more about exceptions on the CMS website.
- Learn about coverage determination and exceptions on the Medicare Interactive website.
Have questions?
Contact us at the Office of the Health Care Advocate (HCA) by filling out our form or calling 1-800-917-7787. There is no charge for our help. If you have a time-sensitive, urgent need, please call us instead of using our form.
You also may want to talk to your doctor to see if there is a similar or generic prescription that will work for you that your Part D plan will cover.
Switching Part D plans
You may also want to see if you have special enrollment period that allows you to switch to a Part D plan that covers the medication.
If you have Extra Help or Medicaid, you are entitled to one special enrollment period once per calendar quarter during the first nine months of the year.
If you have VPharm, you are entitled to one special enrollment period per year to switch Part D plans.
