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Appeals and Exceptions: How Does It Work?



If your plan has a deductible, your plan may not pay anything toward the cost of a medicine until you have met your deductible—even if the medicine is covered (on your plan's formulary). Before you request coverage, be sure to ask your pharmacist why your plan did not pay.

Requesting coverage when your medicine is not covered can help you get the medicines you need to stay healthy. It can also help you control your costs. You can start the process and then wait for approval to get a medicine that is not covered. Or, if you need the medicine right away, you can pay for the medicine yourself and then start the process to ask the plan to pay you back.

First you must formally ask your plan to cover your medicine. This request is called a coverage determination. Some kinds of coverage determinations, called exceptions, require a statement from your health care provider explaining why the medicine you are seeking is medically necessary. After the coverage determination, Medicare has a formal appeal process that you can use to ask your Medicare drug plan to re-evaluate a denial of coverage. It's important to use the specific terms that Medicare uses for each step in the process.