What to Do If Medicare Denies Coverage for Prescription Drug

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.

Posted on January 9, 2023

Medicare can initially refuse to cover prescriptions for a variety of reasons, such as when your plan does not 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 does not 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 is no viable replacement for the medication or you are not 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.

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While asking for an exception, it is 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. For 2022, 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 in 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.