If your pharmacist tells you that your Medicare drug plan won’t cover a drug you think should be covered, or it will cover the drug at a higher cost than you think you are required to pay, you have the right to the following:
- Request a coverage determination from your plan.
- Pay for the prescription, save your receipt, and ask the plan to pay you back by requesting a coverage determination.
- Request a coverage determination if your plan requires you to try another drug before it pays for the drug prescribed for you, or there is a limit on the quantity or dose of the drug prescribed for you, and you disagree with the requirement or limit.
You, your doctor, or your appointed representative can ask the plan to cover the prescription you need by calling your plan or writing them a letter. If you write to the plan, you can write a letter or use the “Model Coverage Determination Request” form. You can get a copy of this form by visiting www.cms.hhs.gov/MedPrescriptDrugApplGriev/13_Forms.asp on the web.
If you want to appoint a representative to help you with a coverage determination or appeal, you and the person you want to help you should complete the “Appointment of Representative” form (Form CMS-1696) and send it with your coverage determination or appeal request. You can get a copy of this form by visiting www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf on the web.
You may file either a standard or an expedited (fast) coverage determination request. Your request will be expedited if your plan determines, or your doctor tells your plan, that your life or health may be seriously jeopardized by waiting for a standard request. Once your plan has received the request, it has 72 hours (for a standard request for coverage or for a request to pay you back) or 24 hours (for an expedited request for coverage) to notify you of its decision.
