Medicare Prescription Drug Benefit: How to Request an "Exception"

Linda Wells, Aging and Disability Services Planner

In last month's Seniors Digest, we saw in Medicare Prescription Drug Benefit: If Your Medication Isn't Covered that there are steps you can take if your drug plan doesn't cover a medication you need. If you have followed all the suggested steps with no resolution, there is more you can do.

Ask for an exception

You can ask a Medicare Prescription Drug Plan to make an exception to its formulary so that you can get a medicine that you need. Your doctor or someone you ask to help you can also do this for you. No matter who asks the plan for an exception, the doctor who prescribed the medicine will need to help by talking to the plan or writing to the plan.

The doctor must show that no other drugs offered by the plan will be as effective for you as the drug prescribed. The doctor should also explain if any of the following applies to you:

• Using a different drug may be harmful, because, for example, of side effects or because of your medical condition.
• The plan wants you to try a cheaper drug first, but you have already tried that drug in the past and had problems or found it did not work.
• You would have to take the other drug more often, and it would be hard for you to take the drug that frequently.

The plan may ask your doctor to provide medical records or other documents.

Get a "coverage determination" from the plan

Within 72 hours after you and your doctor ask the plan for an exception, the plan must give your doctor its decision. This is called a "coverage determination." Your doctor can ask that this be "expedited" (speeded up) so that you get the decision within 24 hours, or faster if you need your drug immediately. If you live in a nursing home, the plan must give you an immediate emergency supply of the prescribed drug.

• If the plan decides not to cover the drug, it must give you a written notice.
• If you and your doctor disagree with the coverage determination, you can appeal.

 
File an appeal, if necessary

Ask the plan for a "redetermination" within 60 days of getting the first coverage determination. You and your doctor give the plan more information, and an expert in the plan (such as a doctor who was not involved in the first coverage determination) reviews your case again. The plan usually has seven days to make another decision, but you can ask for a faster decision.

1. If the plan again decides against you, ask in writing for "reconsideration" by an "independent review entity." You have 60 days to do this. People who are not part of the plan and who are experts in treating your medical condition will look at the evidence and make a decision within 7 days, or if you have an urgent case, within 72 hours. You, your doctor, the plan, and Medicare will get copies of the decision.
   
   
2. If you still disagree, you may be able to appeal to an Administrative Law Judge and then through the Medicare Appeals Council of the Departmental Appeals Board.

If you need assistance with Medicare Part D, please contact the Statewide Health Insurance Benefits Advisors (SHIBA) HelpLine for King County at 1-888-680-6880, or click here to visit the website.