Requesting an Exception (Coverage Determination)

Printer-friendly versionPrinter-friendly version

You, your authorized representative or your doctor may request an Exception (also called a Coverage Determination) by filing a signed statement with your Part D Plan, or in some cases by calling your Part D Plan. Even if you or your representative files the request, your doctor must provide a statement of medical necessity.

If your health is in serious jeopardy the request for an Expedited Exception (Coverage Determination) can always be done by calling your Part D Plan Learn about Expedited Exceptions (Coverage Determinations) below.

You have the RIGHT to request an Exception when:

  • Your drug is a Part D medication, but your Part D Plan does not cover it, or
  • Your Part D Plan will cover your medication but only if you obtain a Prior Authorization, or
  • Your Part D Plan will cover your medication but not in the quantity your doctor prescribed, or
  • Your Part D Plan will not cover your medication unless you have previously tried cheaper medications on the Formulary and they did not work well or you had side effects, or your doctor says you cannot take the cheaper medications, or
  • Sometimes when you cannot afford the co-payment for your drug and your Part D plan offers other drugs at a lower price.

Normally you should ask your prescribing doctor to request an Exception (Coverage Determination ) for you. You can request one yourself or ask someone you trust to do that, although you will still need a statement of medical necessity from your doctor.
NOTE: If someone other than your prescribing doctor is going to request an Exception (Coverage Determination) for you, you will need to submit a written statement to your Part D plan authorizing someone to act for you. You can get the Standard Authorization Form from the Centers for Medicare and MaineCare Services.
What happens next?
Your Part D plan must issue a Decision within 72 hours after it receives your doctor's statement unless you requested an Expedited Exception (Coverage Determination).

What if I can't wait 72 hours?

You, your doctor, or your authorized representative can request an Expedited Exception (Coverage Determination). If you or your doctor believes that waiting 72 hours for a Decision might seriously jeopardize your health, life, or ability to regain maximum function, your doctor (or you) can call your Part D plan and request an Expedited Exception (Coverage Determination).
NOTE: Your Part D plan MUST grant a request for an Expedited Exception (Coverage Determination) if your doctor personally calls your 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 Part D plan grants the request for an Expedited Exception (Coverage Determination), it must issue a Decision and contact you within 24 hours after it receives your doctor's statement.

What if the Exception (Coverage Determination) decision is unfavorable?

Contact your doctor to discuss the decision. If your doctor believes the decision is incorrect, you, your authorized representative, or your doctor can request a Redetermination Appeal.

NOTE: You have the RIGHT to Appeal the denial of an Exception/Coverage Determination.
For questions or advice, contact
the Medicare Part D Appeals Unit at
Legal Services for the Elderly at 1-877-774-7772.

Your Part D plan's written Exception (Coverage Determination) denial decision will explain how to request an Appeal.

We have more information about the Appeal process.