Guide to Medicare Part D: My Part D Plan Denied Coverage Of My Drug. How Do I Find Out Why I Was Denied Coverage?

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This page is part of our Guide to Medicare Part D.

To find out why your prescription was not filled:

  • You could ask the pharmacist for an explanation.

    The pharmacist may or may not be able to explain the reason why you were denied coverage. Depending on the reason for the denial, you may be entitled to request an Appeal or an Exception; to obtain your drug.

    There are several reasons why your Part D plan might refuse to cover your drug. Use the links at the bottom of this page to find out what to do next.

  • If the pharmacist does not give you a reason for the denial, contact your Part D plan and request a "Coverage Determination."

    A "Coverage Determination" is your Part D plan's official decision about the prescription drug benefits you are entitled to receive.

Your request for a "Coverage Determination" must be in writing, UNLESS your health is in serious jeopardy.

see below for more on Expedited Coverage Determinations.

If you need assistance requesting a "Coverage Determination," you can ask your prescribing doctor or someone you trust to request a "Coverage Determination" for you.

NOTE: You will need the help of your doctor to pursue a successful appeal or exception. Your doctor must be able to certify that the drug that is not covered is necessary and that no other drug can safely be used to replace it.

If someone other than your prescribing doctor is going to request a "Coverage Determination" for you, you will need to submit a written statement to your Part D plan authorizing someone to act for you.

You can request a standard Authorization form from Medicare to complete and send in so that Medicare can allow that person to help you with the appeal. (Without the form they cannot talk about your appeal with anyone other than you or your recognized legal representative.)

What happens next?

Your Part D plan must contact you within 72 hours to explain the reason why it would not cover your drug.

What if I can't wait 72 hours?

You can request an Expedited Coverage Determination.

If you or your doctor believes that waiting 72 hours might seriously jeopardize your health, life, or ability to regain maximum function, you or your doctor can call your Part D plan and request an Expedited Coverage Determination.

Your Part D plan will decide if you qualify for an Expedited Coverage Determination depending on the seriousness of your health condition.

NOTE: Your Part D plan MUST grant a request for an Expedited Coverage Determination if your doctor personally calls your Part D plan and states that waiting 72 hours for a decision might seriously jeopardize your health, life, or ability to regain maximum function.

If your Part D plan grants the request for an Expedited Coverage Determination, it must contact you within 24 hours to explain the reason why it would not cover your drug.

What if the Coverage Determination is unfavorable?

There are several reasons why your Part D plan might refuse to cover your drug. Follow the links below to find out what to do next.

For questions or assistance, contact
The Legal HelpLine for Older Kentuckians
1-800-200-3633


Reviewed August 2009

This online guide was adapted with permission from Maine Legal Services for the Elderly. We extend our thanks to them.