My Part D plan denied coverage of my drug. How do I find out why I was denied coverage?

To find out why your prescription was not filled:

• You could ask the pharmacist for an explanation.

  The pharmacist may or may not be able to explain the reason why you were denied coverage. Depending on the reason for the denial, you may be entitled to request an Exception (Coverage Determination); to obtain your drug. If your Coverage Determination is denied, you have the right to Appeal the denial.

  There are several reasons why your Medicare Part D plan might refuse to cover your drug. Use the links at the bottom of this page to find out what to do next.

• If the pharmacist does not give you a reason for the denial, or if you want an official denial so you can start the Appeal Process, you, or your representative or your doctor, should contact your Medicare Part D plan and request a "Coverage Determination."

  A "Coverage Determination" is your Medicare Part D plan's official decision about the prescription drug benefits you are entitled to receive.

If you need assistance requesting a "Coverage Determination," you can ask your prescribing doctor or someone you trust to request a "Coverage Determination" for you.

NOTE:If someone other than your prescribing doctor is going to request a "Coverage Determination" for you, you will need to submit a written statement to your Medicare Part D plan authorizing someone to act for you. You can get a Standard Authorization Form from the Centers for Medicaid and Medicare Services (CMS).

What happens next?

Your Medicare Part D plan must contact you within 72 hours to explain the reason why it would not cover your drug.

What if I can't wait 72 hours?

You can request an Expedited Coverage Determination.

If you or your doctor believes that waiting 72 hours might seriously jeopardize your health, life, or ability to regain maximum function, you or your doctor can call your Medicare Part D plan and request an Expedited Coverage Determination.

Your Medicare Part D plan will decide if you qualify for an Expedited Coverage Determination depending on the seriousness of your health condition.

NOTE: Your Medicare Part D plan MUST grant a request for an Expedited Coverage Determination if your doctor personally calls your Medicare Part D plan and states that waiting 72 hours for a decision might seriously jeopardize your health, life, or ability to regain maximum function.

If your Medicare Part D plan grants the request for an Expedited Coverage Determination, it must contact you within 24 hours to explain the reason why it would not cover your drug.

What if the Coverage Determination is unfavorable?

There are several reasons why your Medicare Part D plan might refuse to cover your drug. Follow the links below to find out what to do next.

My Part D plan denied my doctor's request for a Coverage Determination and determined that my drug was not medically necessary My drug is not on my Medicare Part D plan's formulary My doctor did not obtain a prior authorization from my Medicare Part D plan My doctor prescribed a dosage that is not covered by my Medicare Part D plan My doctor prescribed a form (liquid versus pill), or type (generic versus brand) of drug that is not covered by my Medicare Part D plan My Medicare Part D plan removed my drug from its formulary I tried to get my prescription filled at a pharmacy that is not within my Medicare Part D plan's network My drug is not covered by Medicare Part D

For questions or assistance,

contact the Medicare Part D Unit at
Legal Services for the Elderly
1-877-774-7772