Using Your Medicare Drug
Plan:
What to Do if Your Medicine
Isn’t Covered SPRING 2007
www.YourPharmacyBenefit.org
Table of Contents How does it work?
When should I request coverage?
How do I know if my medicine is covered?
Who can request coverage?
Requesting coverage: step by step
Requesting coverage: the process at a glance
Writing a letter of appeal
Sample appeal letter
PDF Format
Spanish Version
Index of Definitions
Appeal process
Co-pay (or co-payment)
Co-pay tiers
Coverage determination
Denial
Exception
Expedited request
Formulary
Health care provider
Prior authorization
Health care provider:
When requesting coverage, you will need to work with the person
who prescribed the medicine in question.
This could be a doctor, nurse practitioner, physician assistant,
dentist, psychiatrist or other medical professional.
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Coverage determination: The
first decision made by a plan about the benefits you may be allowed.
|
Exception: A
request that your plan pay for a medicine that it wouldn’t
normally pay for. An exception request usually must include a
statement
from your health care provider.
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Appeal process:Steps
you can take to ask your Medicare drug plan to reevaluate a decision
made about your coverage. Coverage
|
Denial: When you
are told that your plan will not pay anything toward the cost of
a particular medicine any time during the year. |
Your Medicare
prescription drug plan may not automatically cover every medicine prescribed
by your health care provider.
If you find yourself in this situation, you have options. With a little
persistence, you can often get your plan to cover the medicine you need.
Read on to find out when and how to request coverage from your Medicare
plan.
Throughout this guide, you’ll see words in bold letters that you
may not know. These words are often used in health insurance materials,
so learning them will help you understand the information you get from
Medicare and from your plan. We’ve included definitions of these
terms for you on the edge of the page.
How does it work?
First you must formally ask your plan to cover your medicine. This request
is called a coverage determination. Some kinds of coverage
determinations, called exceptions, require a statement from your health
care provider explaining why the medicine you are seeking is medically
necessary. After the coverage determination, Medicare has a formal appeal
process that you can use to ask your Medicare drug plan to re-evaluate
a denial of coverage. It’s important to use the
specific terms that Medicare uses for each step in the process. You can
learn more about the coverage determination and the specific steps in
the Medicare appeal process on page 5 of this booklet.
TIP:
Tip: If your plan has a deductible, your plan may not pay anything
toward the cost of a medicine until
you have met your deductible – even if the medicine is covered
(on your plan’s formulary). Before you request coverage,
be sure to ask your pharmacist why your plan did not pay. |
When should I request coverage? Requesting coverage when your medicine is not covered can help you get
the medicines you need to stay healthy. It can also help you control
your costs. You can start the process and then wait for approval to get
a medicine that is not covered. Or,
if you need the medicine right away, you can pay for the medicine yourself
and then start the process to ask the plan to pay you back.
The information in this booklet
relates to situations when you may want to request coverage because
the medication your health care provider
prescribed is not on your plan’s formulary, so it is not covered
by your plan.
You also may want to request coverage if:
- You made a request for prior authorization that was denied.
- Your plan requires you to try a lower cost medicine first but you
have already tried that medicine unsuccessfully, or your health care
provider knows that you cannot take it for some reason.
- Your plan limits the number of pills you can have of a particular
medicine.
- Your medicine has a high co-pay and you want to ask for a lower co-pay
because similar medicines with a lower co-pay do not work for you or
your health care provider knows that you cannot take them for some
reason.
In these situations the steps in the process are similar, but they
are not described in this guide. For more information, call 1-800-MEDICARE
(1- 800-633-4227).
Formulary: A plan’s list of which medicines it covers and at what
level of copayment. Prior authorization:
A type of coverage determination that requires your health care provider
to get approval from the plan before it will pay for a medicine.
Co-pay (or copayment):
A fixed amount, for example $10, that an insured person pays for health
services or medicines, regardless of the actual cost of that service
or medicine.
TIP: If your
prescription is denied the first time you use a new Medicare drug plan
to refill a medicine you have
been taking, you, your pharmacist, or your health care provider should
ask the plan for a “transitional supply.” This gives you
and your health care provider 30 days to decide if you should switch
to a medicine that is covered or request coverage from your plan. Be
sure to take action, or your medication may not be covered at your
next refill!
How do I know if my medicine
is covered?
Medicare drug plans all have a formulary. The medicines on the formulary
are grouped into co-pay tiers, or preferred drug levels.
There are often tiers for generic drugs, preferred brand name drugs,
nonpreferred brand name drugs, and specialty drugs. The tier a medicine
is on determines how much your co-pay will be.
If your medicine is not on the formulary, coverage will be denied.
Your plan can also:
- set limits on how many pills of a certain medicine you can get in
a month or a year,
- require prior authorization or,
- require you to try a less expensive medicine before agreeing to pay
for the one your health care provider originally prescribed.
Your plan can make changes to its formulary, like adding or removing
medications or changing tier assignments, any time during the year. If
a plan decides to remove a medication you are taking from the formulary
or change it to a different tier mid-year, the plan must tell you 60
days before it makes the change.
Unless a medicine you take is removed from the formulary because (1)
a generic version of the medicine has become available or (2) there is
a safety reason, the plan must continue to cover it for you until
the end of the plan year. This is to give you and your health
care provider time to determine:
- whether another medicine that the plan covers will work for you,
- whether you want to request a coverage determination, or
- whether you want to join
a different plan next year – one that
will
cover the medication you need.
You usually cannot switch to a new plan until the annual open enrollment
period, even if your current plan takes your medication off its formulary
mid-year.
Co-pay tiers: Groups of medicines with the same co-payment. Plans assign
each medicine on the formulary to a tier. There can be 2, 3, or more
tiers, each with a different copayment amount.
Who can request coverage?
If you have Medicare, you have a right to request a coverage determination
and use the Medicare appeal process. In some cases, you may need information
from your health care provider or other kinds of help in order to make
your request. Medicare beneficiaries may appoint a representative who
can act on their behalf in the Medicare appeal process.
To
name an appointed representative, call the member services number on
the back of your pharmacy benefit ID card and ask to have the appropriate
form sent to you, or download one from the Centers for Medicare & Medicaid
Services at www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf. You and your appointed representative must
both sign the form before you send it back to the plan. An appointed
representative may do anything that a Medicare beneficiary can do in
the Medicare appeal process, including filing a request, submitting evidence,
and receiving notices from your plan.
Your appointed representative may be any willing person you choose,
including a:
- relative
- friend
- doctor, pharmacist, or other health care professional
- lawyer
You may have a different
appointed representative for each medicine. Medicare beneficiaries
who cannot make their own medical decisions may
have a court appointed guardian or conservator act on their behalf, according
to state laws.
TIP: Your health care provider is not
automatically your appointed representative. If you want your health
care provider to help you with the Medicare appeal process, you must
file a form to designate him or her, just as if you were designating
a friend or relative.
Requesting coverage: step by
step
If you and your health care provider agree that you need a medicine that
is not covered, you can request coverage. Most requests will be settled
at the first step of the process, called the coverage determination.
When requesting coverage because a medicine you need is not on your plan’s
formulary, you must request a specific type of coverage determination
called a formulary exception. If your request for coverage is denied
you may appeal to the next level using the Medicare appeal process. Each
time you appeal to a higher level and your request for coverage is denied
your plan must send you a written notice including information about
why your request for coverage was denied and how to take the next step
in the Medicare appeal process.
Step 1: Request a formulary exception (a type of coverage determination).
In this step your plan makes a formal decision about whether or not to
cover your medication.
- How to Request: You, your appointed representative, or your health
care provider may make this request by phone or in writing to your
plan. No matter who does this, your plan must receive a statement from
your health care provider explaining the medical reason you need the
specific drug.
- Timeframe: You may make this request at any time.
- Decision: A decision must
be made and sent to you as soon as your clinical condition requires,
but no later than 72 hours (24 hours for
an expedited request) after your health care provider’s statement
is received. Expedited request: A faster review of
your request because your health care provider told your plan that
your life or health will be seriously jeopardized if you must wait
72 hours for the medicine.
TIP: You can usually find the formulary on your
plan's Web site or by calling the member services phone number on the
back of your pharmacy benefit ID card. You can also use the Formulary
Finder at www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227)
to find plans in your state that cover the medications you need.
Step 2: If your formulary exception request is denied, request a redetermination.
In this step a doctor at your plan who was not involved in the original
denial must review the case again.
- How to Request: You or your appointed representative must
make this request in writing to your plan. The letter you received
from your plan in response to your formulary exception request will
tell you where to send your request. There is no special form to use.
A simple letter saying that you want to appeal further should be enough.
For a sample letter, see page 9. Your health care provider is not allowed
to do this for you unless he or she is your appointed representative.
- Timeframe: You must request a redetermination within 60 days
of receiving a denial of your formulary exception request.
- Decision: A decision must be made and sent to you as soon
as your clinical condition requires, but no later than 7 days (72 hours
for an expedited request).
Step 3: If your request for
coverage is not granted after a redetermination, request a reconsideration.
In this step, an independent entity will review
the case and make its own decision.
- How to Request:
You or your appointed representative must make this request in writing
to the “Independent Review Entity” (IRE).
The letter you received in response to your redetermination request
will give you the address and instructions on how to write to the IRE.
- Timeframe: You must make this request within 60 days of receiving
a denial of your request for coverage under the redetermination.
- Decision: A decision must be made by the IRE and sent to you
as soon as your clinical condition requires, but no later than 7 days
(72 hours for an expedited request).
If your request for coverage is denied under the reconsideration and
you wish to appeal further, you may want help from a lawyer. (If you
need help finding a lawyer, contact the Eldercare Locator by calling
1-800-677-1116 or visiting www.eldercare.gov.)
You will get information about how to appeal further when you are told
that your request for coverage has been denied under the reconsideration.
For more information about additional steps in the Medicare appeal process,
see http://www.yourpharmacybenefit.org/medicare/Appeals.asp.
Requesting coverage: the process at a glance
Step: |
How to Request: |
Do This Within: |
Decision Within: |
Request a coverage determination (specifically: formulary exception) |
Call or write to your
plan. Your health care provider must explain why you need the specific
medicine. |
No time requirement |
72 hours of receiving health care provider's statement (24 hours
for expedited request) |
Request a redetermination |
Write to your plan and request a redetermination. |
60 days of formulary exception denial |
7 days (72 hours for expedited request) |
Request a reconsideration |
Write to the independent review entity (IRE) noted in your redetermination
denial letter. |
60 days of denial of redetermination request for coverage |
7 days (72 hours for expedited request) |
Appeal to the Administrative Law Judge (ALJ) |
Follow steps in reconsideration letter. |
60 days of denial of reconsideration request for coverage |
No time requirement |
Appeal to the Medicare Appeals Council (MAC) |
Follow steps in ALJ letter. |
60 days of denial from the ALJ |
No time requirement |
File suit in Federal District Court |
Follow steps in MAC letter. |
60 days of denial from the MAC |
Depends on court schedule |
Writing a letter of appeal
If
your request for a formulary exception has been denied, you will need
to write a letter in order to request a redetermination. This letter
can be very simple; however, it is probably good to include all of
the following information in
the letter so that you establish a written record.
- Your name, address, phone number, and Medicare ID number
- The date you are writing the letter
- The date you tried to fill the prescription
- The name and address of the pharmacy where you tried to fill the
prescription
- The name, address, and phone number of the health care provider
who wrote the prescription
You should also:
- Clearly state that you wish to request a redetermination.
- Include a copy of either
the receipt, if you paid already, or the prescription, if you didn’t. If you don’t
have either of these items, list the exact name and dosage of the
medication
prescribed.
- State that the plan has permission to contact your health care
provider if additional medical information is needed. (It would also
be good to
talk to your health care provider about how to respond to the reasons
why the plan denied your benefit and to let your health care provider
know that you are filing an appeal and that he/she may get a call.)
- Indicate that you expect the plan to tell you everything you need
to do so that your appeal can be processed. Also ask them to tell
you how
you can appeal further if they deny this appeal.
- Respond to the reasons the plan gave for denial in the letter denying
your formulary exception request. For example, if the plan wants
you to try a different medicine first, but you have a bad reaction
to that
medicine, you should explain this.
- Make a copy of your letter for yourself before you mail it.
Sample appeal letter*
[Your Name]
[Your Address]
[City, State ZIP]
[Your Phone Number]
[Your ID Number]
DOB: [Your Date of Birth]
Date
Medicare Prescription Drug Plan Name
Plan Address
City, State ZIP
(You can find this information on the back of your pharmacy
benefit ID card - the one you use when you pick up your prescriptions.)
To Whom It May Concern:
I am writing to request a redetermination. I am covered under your plan and
my ID number is [ID number - Your ID number is on the
front of your pharmacy benefit ID card.]. On [date], I attempted to
fill a prescription for [name of medicine] at the [pharmacy name] Pharmacy
located at [pharmacy address]. I requested an exception and was denied. Your
coverage determination letter said you were denying my claim because [reason
for denial]. I need this medication because [reason why you need this specific
medicine - You may need to ask your health care provider
to provide information explaining why the medicine is "medically necessary."].
[I have already paid for the medication and want to be reimbursed.
OR I cannot afford to pay for this medication myself and need
you to cover it as
soon as possible, since I am currently going without it.]
My contact information
is above, and contact information for [name of health care provider who
wrote prescription], is listed below.
[Name of Health Care
Provider Who Wrote Prescription]
[Health Care Provider Address]
[City, State ZIP]
[Health Care Provider Phone Number]
[Name of health care provider who] wrote the prescription,
and you may contact him/her if medical information is needed
for consideration of my
appeal.
I have included a copy of the [prescription or receipt - If
you don't have a copy of the written prescription or the pharmacy receipt,
list the name of the medication and the dose that you were prescribed. Double
check with your pharmacist to make sure that you have spelled everything correctly
since the names of many medications are similar.] for your consideration.
Please provide me with a written explanation of any additional
steps I must take for you to process my appeal, as well as
a written explanation
of the
basis for your decision about my claim.
Sincerely,
[Your Name] |
* This sample appeal letter is provided for informational purposes only.
Every plan has different rules and procedures for appeals, and this sample
letter may not meet the requirements of your plan. DO NOT USE THIS LETTER
WITHOUT FIRST CHECKING THE SPECIFIC PROCEDURES OF YOUR PLAN FOR APPEAL
LETTERS. Additional Resources
The U.S. Department
of Health and Human Services’ Centers for
Medicare & Medicaid Services has reviewed this publication, which
is produced by YourPharmacyBenefit.org. YourPharmacyBenefit.org is a
collaborative effort among non-profit organizations representing consumers,
physicians, pharmacy, and pharmaceutical companies that strives to educate
consumers to make informed decisions when choosing and using their pharmacy
benefits, thus empowering them to access the medicines their health care
providers prescribe. This publication may be reprinted for educational
and nonprofit purposes. To request additional copies of this booklet, write to:
Federal Citizen Information Center
Publication Number 661P
Pueblo, CO 81009
or go to www.pueblo.gsa.gov
YourPharmacyBenefit.org
1894 Preston White Drive
Reston, VA 20191-5433
www.YourPharmacyBenefit.org 1PTC0070507
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