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Appeals and Exceptions: Requesting Coverage Step by Step



You can usually find the formulary on your plan's Web site or by calling the member services phone number on the back of your pharmacy benefit ID card.

You can also use the Formulary Finder at www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to find plans in your state that cover the medications you need.

If you and your health care provider agree that you need a medicine that is not covered, you can request coverage. Most requests will be settled at the first step of the process, called the coverage determination. When requesting coverage because a medicine you need is not on your plan's formulary, you must request a specific type of coverage determination called a formulary exception. If your request for coverage is denied you may appeal to the next level using the Medicare appeal process.

Each time you appeal to a higher level and your request for coverage is denied your plan must send you a written notice including information about why your request for coverage was denied and how to take the next step in the Medicare appeal process.

Step 1

 Request a formulary exception.
Step 2

Request a redetermination.
Step 3

Request a reconsideration.