Appealing A Medicare Drug Refusal Decision Because of A Formulary Issue

 What happens when your doctor prescribes a medication and your Medicare Part D (Drug Plan) refuses to cover it because it is not on their formulary.  Even though the medication might not be on the formulary, you still might be able to get your Medicare insurance to pay for it!   

Before we get into how you might be able to Medicare to pay for this drug you need to understand what is a formulary.  A plan’s formulary is just a list of prescription drugs that the insurer agrees they will cover.  Not all drugs are in an insurance company’s formulary even if they are FDA approved.

If your doctor prescribes a drug which is not covered (not on their formulary), it means that your plan usually will refuse to cover its cost. This does not mean that they will never cover it, it means that you still have options to get the coverage for the drug or a similar drug, but you will need to do some work to try and get coverage.

When you are informed that the insurance company will not cover the drug, the first thing you should do is speak with the doctor who prescribed the medication. Ask them if there might be an alternative, but an equally effective drug that might be on your plan’s formulary.   

If your doctor believes that you need the specific off-formulary medication, because the alternative medications that are on your plan’s formulary would not be safe or if they would be ineffective have your doctor work with you to make a formal appeal to try and get the medication covered by the insurer.

Standardly, the appeal process will require that you or your doctor file an exception request (a formal coverage request) with your drug provider. To find out how to do this you should contact your insurance plan directly and ask them how to file an Exception Request. It is imperative that you include in your Exception Request a strongly worded and very specific letter of support from your doctor explaining why you require the particular medication and why the alternatives that are on the formulary would not be as good for you. Either your doctor or by you should file the Exception Request. Under the Federal Law, your Medicare Part D Carrier is required to issue a decision within 72 hours of their receiving your Exception Request.

In circumstances where waiting the 72 hours for a formal answer, based on your opinion or the opinion of your doctor, is too long because waiting might cause you severe medical harm, you have the right to request a fast, Expedited Exception Request. If your doctor supports the request, the insurance carrier is required to follow an expedited timeline. 

However, if your doctor does not agree that waiting the 72 hours puts you at additional severe risk for a routine determination, you still may request an Expedited Exception Request without your doctor’s support.  However, without your doctor’s support, your plan does not have to follow the expedited timeline. 

Under normal circumstances, the expedited process usually will provide you with a decision within 24 hours of your request.

If your Exception Request is approved, your drug will be covered by your insurance carrier. If your Exception Request is denied, your plan will send you a Notice of Denial of Medicare Prescription Drug Coverage. 

Even in the circumstances when the request is denied you still have the right to file an appeal.  You have 60 days to file the appeal, however, the 60 days to be a hard and timeline. The 60-day timer begins from the date listed on the Notice of Denial. The appeal process is the same and is under the same deadlines regardless of whether you are appealing under a standard or expedited review. It is crucial that you carefully follow the directions on how to file an appeal that will accompany the Denial Notice you receive. 

If you, not your doctor, is appealing, ask your doctor to write a letter of support that clearly and specifically addresses the plan’s disclosed reasons for not covering your medication. Your plan should issue a decision within seven days, or within 72 hours if you are filing an expedited appeal.

If your plan approves your appeal, your drug will be covered.  In the circumstances where the appeal is rejected (you will receive a denial notice) there is still one additional strategy you can use to get coverage. 

You can still appeal this denial.  The denial letter will tell you that you can make an additional appeal.  Make sure that you are very careful and completely follow all the instructions on the Denial Notice.  During the appeals process, you can choose to pay out-of-pocket to get the drug your plan is denying. If you do pay out of pocket and you eventually win the appeal, the plan should reimburse you for your out of pocket costs, so make sure that you keep all of your receipts and submit them to your insurance plan.