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More Resources: FAQs About Your Plan

Question 3: How do I request coverage of prescriptions the PDP denied?

Find out about the Medicare appeal process offered by the PDP. If you really need a medication because of a valid medical reason, you can often get it covered. But you must go through the Medicare appeal process. The first step is to ask the PDP for a coverage determination . If the PDP agrees that you really need the medication based on the information your health care provider gives the plan, then the request for coveragewill be granted. If not, you will receive a denial notice that includes information telling you how to use the Medicare appeal process. There are several additional levels of appeals, so you can appeal to external agencies if you are not satisfied with the PDP's response. If you can't wait for the process to finish, you may need to pay for the drug yourself and then file an appeal to be paid back by the plan later.

You should be aware that you probably will not be notified of your right to request a coverage determiniation when you are first told that the prescription can't be filled. So you must become familiar with how to make the request on your own initiative.