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How To Maximize Use Of Medicare Part D

When And How To Ask For An Exception (Appeal)

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If any of the following situations occur, you can ask your Plan for an Exception if:

  • A drug you need isn't on a formulary
  • If the Plan raises the amount you pay for a drug.
  • If a drug you need is subject to a high copay.
  • Your Plan replaces a brand name drug you are taking with a generic version and only the brand name will work for you.
  • Your plan requires that you take another drug first.

Before asking for the Exception, speak with your doctor to find out if another drug on the Formulary will work for you. If so, change your prescription to the covered drug.

If not, ask your doctor to request an exception. Your doctor has the medical knowledge needed to justify a request about the effectiveness of a drug. Even if the question is financial, a significant factor in the request is that another drug on the formulary won't work as well for you.

If your doctor won't contact the plan for you, if the question is about medical necessity, at least get a written statement from your doctor about the need for an exception. If you're not comfortable negotiating, ask a seasoned friend or family member to contact the Plan for you.

  • Follow the Plan's rules.
  • Ask your doctor to call or write the Plan. If he or she won't, ask for a letter explaining why this is the only drug that works for your particular situation.
  • The insurer must respond within 72 hours (24 hours if medically necessary.) If your Plan denies an exception request, you can always appeal. The denial letter from your Plan will explain how to appeal, and the time limit for the appeal.
  • Once you go through the Plan's appeal process, you are entitled to a review by:
  • An Independent Review Entity (formerly "Independent Contractor").
  • Then, an Administrative Law Judge.
  • Then by the judicial system if you claim meets minimum dollar amounts.

It is not advisable to appeal on your own. The appeal can involve complex medical questions. An excellent, free, source of help is the Medicare Rights Center, offsite link, Tel.: (Consumer Hotline): 800.333.4114 9AM -- 6PM ET

You cannot ask for an exception for drugs which are specifically excluded from coverage, such as weight loss drugs.

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