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 someone you ask to act on your behalf can call or write to your plan to request that the plan cover the prescription you need. Once your plan receives the request, it has 72 hours (for a standard request) or 24 hours (for an expedited (fast) request) to make its decision.
Note: For some types of coverage determinations called exceptions, you will need a supporting statement from your doctor that explains why you need a certain prescription drug. Check with your plan to find out if a supporting statement is required. Once your plan receives the statement, its decision-making period begins.
If the plan decides not to cover your prescription drug, you can appeal the decision. When you enroll in a Medicare drug plan, the plan will send you information about the plan’s appeal process. Read the information carefully and call the plan if you have questions.
