Exceptions and Appeals How To

Q. My Medicare prescription drug plan does not cover all of my medications. What can I do to avoid paying full retail price for a prescription?

Step 1: Exceptions Process

A. Each Medicare private drug plan will have its own list of covered drugs (formulary). You may not be able to find a plan that covers all of your medications, or you may find one that does now but then get a new prescription that isn't on the formulary. Also, the plan in which you are enrolled may require you to try another drug first, or has a limit on the drug prescribed.

Fortunately, you have rights under the new drug benefit that provide some measure of protection that you will get the medicines you need. You have the right to request that your plan cover a "medically necessary" drug that is not on its formulary. This is known as an exception .

An exception is appropriate when:

your doctor prescribes a drug not on your plan's formulary because your doctor believes the drugs on the plan's formulary will not work for you or would be harmful, or;

you are using a drug that is currently covered by your plan, but that drug is removed from your plan's formulary for reasons other than safety, or;

you are using a drug that is subject to step therapy (requires trying another drug first) or quantity limits.

You, someone you appoint, or your prescribing doctor may request an exception from your drug plan. You will need to get your doctor to tell the plan in writing or by phone why you need the particular drug.

Generally, plans must grant these requests for coverage when you can show that it is medically appropriate that they do so. The plan must respond to your request within 72 hours. You can also file an expedited request if your doctor certifies that your "life, health or ability to regain maximum function" is in jeopardy. Plans must respond to an expedited request within 24 hours.

If a plan grants your request, it will tell you how much your co-payment will be for the drug. The plan must continue to cover refills for the rest of the calendar year as long as the doctor continues to prescribe that drug (unless there is evidence the drug is unsafe). When a new calendar year starts, you may have to ask for another exception.

Q. What if I am unhappy to my plan's response to my exception request?

Step 1: Appeals Process

A. If a plan makes an unfavorable coverage determination such as denying an exception request, the enrollee, or his or her appointed representative, may appeal the plan's decision. There are five (5) levels to the appeals process to which an enrollee is entitled:

Level	Action	Standard Appeal	Expedited Appeal*
1	Redetermination by prescription drug plan	If the plan's initial exception request is denied, an enrollee may request a *redetermination* and the plan has up to 7 days to make its decision.	Same as standard, except the timeframe is up to 72 hours for the plan to make its decision.
2	Reconsideration by Independent Review Entity (IRE)	If the prescription drug plan's redetermination is unfavorable, an enrollee may request a *reconsideration* by an IRE, which is a CMS contractor that reviews determinations made by a plan. The IRE has up to 7 days to make its decision.	Same as standard, except the timeframe is up to 72 hours for the IRE to make its decision.
3	Administrative Law Judge (ALJ)	If the IRE's reconsideration is unfavorable, an enrollee may request a hearing with an ALJ if the minimum dollar requirement is met.	Not applicable.
4	Medicare Appeals Council (MAC)	If the ALJ's finding is unfavorable, the enrollee may appeal to the MAC, an entity within the Department of Health and Human Services that reviews ALJ's decisions.	Not applicable.
5	Federal District Court	If the MAC's decision is unfavorable, the enrollee may appeal to a Federal District Court if the minimum dollar requirement is met.	Not applicable.

* An expedited appeal is requested based on the urgency of an enrollee's health condition.

Nebraska Senior Health Insurance Information Program (SHIIP)
1-800-234-7119