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Appeals and Exceptions: When Should I Request Coverage?



If your prescription is denied the first time you use a new Medicare drug plan to refill a medicine you have been taking, you, your pharmacist, or your health care provider should ask the plan for a "transitional supply." This gives you and your health care provider 30 days to decide if you should switch to a medicine that is covered or request coverage from your plan. Be sure to take action, or your medication may not be covered at your next refill!

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.

The information here relates to situations when you may want to request coverage because the medication your health care provider prescribed is not on your plan's formulary), so it is not covered by your plan.

You also may want to request coverage if:

  • You made a request for prior authorization that was denied.
  • Your plan requires you to try a lower cost medicine first but you have already tried that medicine unsuccessfully, or your health care provider knows that you cannot take it for some reason.
  • Your plan limits the number of pills you can have of a particular medicine.
  • Your medicine has a high co-pay and you want to ask for a lower co-pay because similar medicines with a lower co-pay do not work for you or your health care provider knows that you cannot take them for some reason.

In these situations the steps in the process are similar, but they are not described in this guide. For more information, call 1-800-MEDICARE (1- 800-633-4227).