Medicare Rx Benefit Appeals

The new Medicare prescription drug program (Part D) is the single biggest change to Medicare in 40 years. Adding a benefit as significant as this involves some start-up challenges related to Medicare enrollees getting the medicines they need. The following information provides a process in which members may resolve grievances, coverage determinations and appeals under the Medicare Part D Program.

Grievance
A grievance is any complaint or dispute expressing dissatisfaction with any aspect of the operations, activities, or behavior of a Medicare Part D plan sponsor.

• Enrollee may file a grievance with the plan orally or in writing

• Enrollee must file a grievance within 60 days of event

• Enrollee must be notified of the decision no later than 30 days after the plan receives the grievance

• If the grievance relates to a plan’s refusal to expedite a coverage determination, the enrollee must be notified of the decision no later than 24 hours after the plan receives the grievance

Coverage Determination
A coverage determination is the initial decision made by, or on behalf of a Part D plan sponsor regarding payment or benefits to which an enrollee believes he or she is entitled.

Exception
An exception is a type of coverage determination that is unique to the Part d benefit. An enrollee may request a tiering exception or a formulary exception.

• Tiering Exception permits enrollees to obtain a non-preferred drug at the cost-sharing amount applicable to drugs on the preferred tier.
• Formulary exception ensures that enrollees have access to medically necessary Part D drugs that are not included on a plan’s formulary. An exception may also be requested when a plan places quantity or dose restrictions or the requirement that the enrollee try another drug before the plan sponsor will pay for the requested drug.

A Part D plan sponsor must notify an enrollee of its coverage determination as expeditiously as the enrollee’s health condition requires, but no later than 24 hours after receiving an expedited request, or 72 hours after receiving a standard request.

Appeal
If the Part D plan sponsor makes an adverse coverage determination, the enrollee may request an appeal, which is a process by which an enrollee may challenge a plan’s coverage determitation. There are five levels of appeal available:

1. Redetermination by the drug plan
2. Reconsideration by an Independent Review Entity
3. Administration Law Judge Hearing
4. Review by the Medicare Appeals Council
5. Federal District Court Review

The exception and appeals processes are designed to protect Part D plan enrollees and to ensure they get all medically necessary drugs prescribed for them. If questions arise or if enrollees need assistance with the processes, Senior LinkAge Line® can help.

Updated 07/13/2007