When to Request a Medicare Coverage Determination

By Patricia Barry

Copyright © 2015 AARP

A coverage determination always relates to coverage or payment issues in the Medicare Part D prescription drug program. And you have the right to appeal if the decision goes against you.

Whether you’re getting drug coverage from a stand-alone Part D drug plan or a Medicare Advantage plan that provides medications as well as medical care, you can request coverage determinations in two distinct situations:

  • Asking for your meds to be covered: You have the right to ask your plan to take the following actions, but be sure to always do so with your doctor’s help:

    • Cover a drug not on its formulary (list of covered drugs): You’re requesting an exception to the plan’s general policy on the basis that you need this drug for sound medical reasons.

    • Waive a restriction: You want the plan to set aside a restriction — such as prior authorization, quantity limits, or step therapy — it has placed on one or more of your drugs.

    • Cover an excluded drug: In most cases, plans have the right to refuse to cover any drugs that Medicare excludes from Part D. But sometimes Medicare pays for these meds if they’re prescribed for a specific medical condition that Medicare accepts.

    • Charge you a lower co-pay: If your doctor thinks that a nonpreferred, brand-name drug on your plan’s formulary is the only one that works effectively for you, you can ask for it to be covered at the plan’s preferred-tier charge.

  • Asking for certain costs to be paid: You can also ask your plan for a coverage determination in matters related to your pocketbook, as well as to your health. You don’t need your doctor’s support in the following situations:

    • You think the plan is charging you at a higher tier level than it should. Sometimes a plan moves a drug into a higher tier of charges. If this happens when you’re already taking the drug, the plan should charge you the lower-tier co-pay for the rest of the calendar year.

    • You want to be reimbursed for going to an out-of-network pharmacy. You’ve gone out of network for a good reason, but the plan won’t reimburse the extra charges you’ve paid. Send copies of the pharmacy receipts when making this determination request.

    • You want the plan to reimburse you for the cost of drugs you’ve already paid for. This scenario may crop up in a number of situations when you may pay out of pocket for a time, such as if confirmation for your enrollment or eligibility for Extra Help is delayed.

    • You believe the plan isn’t charging you appropriately for the phase of coverage you’re in. For example, you think you’re being charged doughnut-hole rates when you’re not in the coverage gap.

If you’re filing for a determination about any payment-related issues, you can call the plan and file on the phone or (preferably) write a letter or use a form that the plan provides for this purpose. The advantage of using a form is that it tells you what information is required. But if you call or write a letter instead, be sure to use the correct terminology. Say, “I want to request a coverage determination because . . ..” The plan should respond within 24 hours.