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Medicare Resources - Appeals Process

Medicare Exceptions Appeals Process

Have you, a friend, or someone you care for joined a Medicare prescription drug plan (PDP) and had difficulty getting prescription medicines? This information may help you, your friend, or the person you care forget those prescriptions filled.

What should I do when my prescription can't be filled?
You should contact your Medicare drug plan, and ask for an explanation (also known as a coverage determination request) to find out the reasons that the prescription is not covered. If your prescription was not filled because the drug is not on the plan's list of covered drugs (formulary), you may have to ask for an exception.

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What is an exception?
An exception is a request generally made by you or your doctor asking your Medicare PDP to pay for a medically necessary drug that is not normally covered. For a list of your preferred drugs, contact your plan. You have the right to ask for an exception if your doctor believes you need a drug that is not on your plan's list of covered drugs (formulary) or if your doctor believes you cannot satisfy a requirement that applies to the prescribed drug. You can also ask to have a nonpreferred drug covered at the cost-sharing that applies to preferred drugs.

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Are there situations when I cannot request an exception?
Yes, there are 3:

  • You cannot get an exception to cover a nonpreferred drug at a generic drug co-payment. You can only request your drug to be covered at the preferred branded price.
  • If the plan has a separate tier for specialty drugs, such as biotech products, you cannot get an exception for them at a lower cost.
  • Certain types of drugs are excluded from all Medicare PDPs. Some examples include over-the-counter drugs, weight loss drugs, and benzodiazepines.

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What can I do if my request for an exception is denied?
Please click here for more information about filing a Medicare appeal from www.medicare.gov.

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