What To Do if Medicare Denies Coverage for Prescription Drug
Entrusted Legacy Law
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Feb 17, 2023
Pennsylvania - Greater Pittsburgh Area
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Receiving a denial at the pharmacy for a drug you need can
be a stressful experience. When Medicare declines to cover a prescription, some
might worry that they cannot afford the medicine out of pocket. Others might
also need the treatment immediately and become concerned that the lack of
coverage will adversely affect their health.
Medicare can initially refuse to cover prescriptions for a
variety of reasons, such as when your plan doesn’t typically include your
medication on its roster of covered drugs. Still, you have the right to ask
your plan to cover the treatment you need and request an appeal if you disagree
with your plan’s decision not to include your medication.
Steps to Take Following a Prescription Denial
If your plan doesn’t cover a drug, inform the health care
professional who prescribed it. Your prescriber might be able to find an
alternative medication that your plan includes. For instance, you might be able
to switch from a name-brand medicine to a generic one.
In the event that there’s no viable replacement for the
medication or you aren’t satisfied, you have the right to ask Medicare for an
exception so that your plan covers the medicine. Your prescriber can also
advocate for you and reach out to Medicare on your behalf.
As a Medicare beneficiary, you have the right to receive a
coverage determination outlining the reasons for the rejection, and you have
the right to ask for an exception.
While asking for an exception, it’s helpful to have the
support of your doctor or the person who prescribed the medicine. For instance,
your doctor may help your case by writing a letter explaining why you need the
medication.
If, following your request, Medicare refuses to cover the
medicine, you can appeal or appoint a trusted medical professional as
your representative to appeal on your behalf.
There are five levels to the appeals process. To begin this
process, you can have Medicare issue a redetermination of your plan and then
ask an Independent Review Entity to revisit it.
The Office of Medicare Hearings and Appeals (OMHA) examines
coverage decisions for drugs that meet a minimum value, and the Medicare
Appeals Council reviews the judgments of OMHA. The medicine must cost at least
$180 for an OMHA assessment. To reach this amount, appellants can combine the
values of multiple drugs.
When coverage denial persists, beneficiaries can appeal to
the federal district court. To reach the federal district court, the minimum
value of the treatments must be $1,760 as of 2022.
How to Respond If You Need the Medication
Immediately
Those who need the medication urgently can request an
expedited appeal and receive a decision on the exception request within 72
hours. Medicare’s failure to cover your treatment must compromise your life,
health, or ability to regain maximum function.
For assistance with appealing a coverage denial, speak with an attorney who understands Medicare’s appeal process.
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