December 2023: Part D Appeals

Dcember 2023: Part D Appeals

Part D appeals at a glance:

  • If your plan won’t cover your medication, you can appeal the decision.
  • The process is the same whether you get your drug coverage through a stand-alone Part D plan or a Medicare Advantage Plan.
  • Instructions for how to appeal will always be on your denial notice.
  • Your doctor can appeal on your behalf or write a letter of support to help your appeal, but they aren’t required to do so.
  • There is more than one level of appeal, and you have the right to continue appealing if you aren’t successful at the first level.
  • Keep documentation throughout and pay attention to deadlines.


Start with an exception request

If your plan won’t cover your prescription drug, your pharmacist should give you a notice called Medicare Prescription Drug Coverage and Your Rights.

After getting this notice, call your plan to find out the reason it isn’t covering your drug. For example:

  • The drug isn’t on the plan’s list of covered drugs.
  • You may need to request approval from the plan before it will cover that drug.
  • Your plan may require that you try a different, usually less expensive drug first.
  • Your drug has been prescribed for off-label use.

Once you know why your drug isn’t covered, speak to your prescribing physician about your options. For example, you may be able to try a comparable drug that your plan does cover.

If switching to another drug isn’t an option, you’ll need to file an exception request with your plan. This is a formal coverage request, and you can contact your plan to learn how to file one. You should ask your doctor for a letter of support for your exception request.

If your request is approved, your drug will be covered. If it’s denied, your plan will send you a Notice of Denial of Medicare Prescription Drug Coverage. This is your formal denial notice from the plan, and now you can choose to begin a formal appeal.


The Part D Appeals Process

You have 60 days from the date listed on this notice to file an appeal. Directions on how to appeal are on your denial notice. Your provider may appeal on your behalf or help you with the appeal process, but they aren’t required to do so. If a doctor is not appealing on your behalf, you should ask them to write a letter of support addressing the plan’s reasons for not covering your drug. If your plan approves your appeal, your drug will be covered. If your appeal is denied, you can choose to move to the next level of appeal.

There are four levels of appeal after this initial step. At each level, if you are denied, follow the instructions on the denial notice to submit your next appeal. Follow all deadlines carefully. If your appeal is approved at any point, your Part D plan should cover your drug until the end of the calendar year. Be sure to ask your plan if they will continue to cover the drug after the year ends. If they will not, you can appeal again next year, or consider switching Part D plans during Fall Open Enrollment Period to a plan that does cover your drug.