Q: My prescription drug plan denied coverage on a medication to control a severe chronic health problem. Over the years I’ve tried other treatments but they are either ineffective, or had dangerous side effects, and I had to stop taking them. The plan dropped coverage for 2015, but I didn’t learn about that until I tried to refill my prescription. Because I need the medicine, I’ve paid full retail cost using a credit card. I’m carrying debt now that will take me a long time to pay off. Is there anything I can do?
A: You have the right to ask your plan to provide or pay for a drug that you think should be covered or continued. And if denied, you should appeal your plan’s decision. Here are the steps to take:
- Get a written explanation called a coverage determination from your Medicare drug plan. The determination needs to state whether your drug is covered, whether you have met the requirements to get a requested drug, how much you pay for a drug, and whether you need to an exception to a plan coverage rule. At the same time,
- Call your doctor. If you have tried alternate therapies and found them ineffective or dangerous to your health, ask your doctor to request an exception to the plan’s coverage rules or formulary if appropriate for you. Your doctor will need to provide a statement explaining the medical reason why the exception should be approved.
- Ask for an exception. Either you or your doctor will need to ask for the exception from your health plan if you believe the coverage rules should be waived. You can also ask for an exception if the drug is on a higher tier (and thus more expensive), because you or your doctor believe you can’t take any of the lower tier (less expensive) drugs for the same condition.
- Contact your drug plan for the exception by phone or in writing. You or your doctor will need to contact the plan to request exceptions for future prescriptions. You should also ask for reimbursement for the prescriptions you’ve already paid for out-of-pocket. That request must be made in writing. Medicare has a standard “Model Coverage Determination Request Form” that you can use to ask your plan for the coverage exception. You can find it online at www.Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) and ask for a copy. Once your plan has gotten your standard request, it has 72 hours to notify you of its decision.
