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Use Your Plan: The Medicare Appeal Process

The Medicare appeal process is a series of steps you can take to ask your Medicare drug plan to reconsider a denial of coverage. View the appeal process steps. If you want to use the Medicare appeal process, it's important to use the specific terms that Medicare uses for each step in the process. For example, the first step in the Medicare appeal process is to request a coverage determination. When using the Medicare appeal process because a medicine you need is not on your plan's formulary, you must request a specific kind fo coverage determination called a formulary exception.

The Medicare appeal process can have many steps. Most requests will be settled at the first step—the coverage determination, but if your appeal for coverage is denied at any step along the way you may appeal to the next level. Each time you appeal to a higher level and your request for coverage is denied your plan must send you written notice that includes information about why your request for coverage was denied and how to take the next step in the Medicare appeal process. Note that only you will receive the notice of denial at any step, not your health care provider. (If you have an appointed representative, that person will receive the notice instead of you.)

It is up to you to take the initiative to pursue the next step because your health care provider may not know your request for coverage was denied.

The most common situation in which you will want to initiate a request for a formulary exception (a type of coverage determination) is when you seek to fill or refill a prescription and are told that the drug is not covered on the formulary. Either you or your health care provider may initiate a request for a formulary exception. Download a form you can use to request a coverage determination. You may need to ask your health care provider for information to complete the form.

You may also write a letter to request a formulary exception. View information about what to include in your letter and a sample letter. In order for your plan to make a formulary exception, the plan must receive a statement from your health care provider explaining why the medication is medically necessary for you. Go to a list of Medicare Prescription Drug Plans by state, including plan-specific information on how to get forms and request prior authorization and formulary exceptions.

You may also want to use the Medicare appeal process if:

• Your medication requires prior authorization by your plan. If your health care provider already requested the prior authorization but the request was denied, your first step is to request a reconsideration, rather than an exception. The prior authorization request was already considered the first step (coverage determination) in the process.
• Your plan requires you to try a lower cost medicine first. This is called "step therapy." If you have already tried the medication your plan wants you to try unsuccessfully, or your health care provider knows that you cannot take it for some reason, you can seek a coverage determination to exempt you from the step therapy requirement.
• Your plan limits the number of doses you can have for a particular medicine. For example, some drug plans only allow patients to have three to six doses per month of certain medicines for conditions such as migraine headaches. If you have more frequent episodes of illness, you may request a coverage determination to be exempt from this quantity limit.

These same steps can also be taken if you wish to request coverage at a lower copayment. Your health care provider will have to explain that lower copay medications on the formulary do not work for you, or that they cause negative health effects for you and therefore your only option is the high copay medicine. However, plans are not required to consider requests for certain very high cost medications that are in a specialty copay tier for "genomics or biotech drugs" (often for cancer).  In addition, you cannot request a lower copay for a brand name medicine if there is a generic version of the same medicine available. In order to get the lower copay, you must take the generic version of the medicine.

If your request for coverage is granted, the health plan must cover the medicine within three to seven days of the decision, assuming you have not yet paid for the prescription. (Once you are told that your request for coverage is granted, you can go back to the pharmacy to get your medicine. You may get a phone call to tell you, but the plan should also send you a written letter. If you had a paper prescription from your doctor and the pharmacy gave it back to you when you were told the medication was not covered, be sure to take it with you. If the pharmacy did not give the paper prescription back to you, they should have it on file.) If you already paid for the medication and are asking to be paid back then the plan must pay you back within 30 days.

For more information about the Medicare appeal process, see also Medicare Prescription Drug Coverage: How to File a Complaint, Coverage Determination, or Appeal from the U.S. Department of Health and Human Services' Centers for Medicare and Medicaid Services.