Drug Coverage Determinations & Appeals

If you need a decision about whether a prescription drug is covered, what you will pay for a medication, or whether a coverage rule applies, you can request a coverage determination.

If you disagree with a drug coverage decision, you have the right to appeal.

This page explains drug coverage determinations, appeals, and your rights under your Medicare prescription drug benefit.

What Is a Coverage Determination?

A coverage determination is a formal decision about your prescription drug coverage.

A coverage determination may be requested when:

• You want to know if a drug is covered. 
• A drug requires prior authorization. 
• A drug is subject to step therapy. 
• A drug is subject to quantity limits. 
• You need a decision before obtaining a prescription. 
• You believe a coverage rule should not apply to your situation. 

A coverage determination is generally the first step before filing an appeal.

Requesting a Coverage Determination

You, your prescriber, or your authorized representative may request a coverage determination on your behalf.

There are two types of coverage determinations:

Standard Coverage Determination

A standard coverage determination is generally completed within 72 hours of receiving your request and any supporting information needed to make a decision.

Expedited (Fast) Coverage Determination

You or your prescriber may request an expedited coverage determination if waiting for a standard decision could seriously harm your health.

If your request qualifies for expedited review, we generally decide within 24 hours after receiving the necessary information.

What If My Request Is Denied?

If we deny a coverage determination, formulary exception request, or tiering exception request, you have the right to appeal.

You generally have 65 calendar days from the date on your denial notice to request an appeal.

You, your prescriber, or your authorized representative may request an appeal on your behalf.

Medicare Part D Appeals Process

There are several levels in the Medicare Part D appeals process.

Level 1: Redetermination (Appeal by Elderplan)

A redetermination is the first level of appeal.

When we receive your appeal, we conduct a new review of the original decision and any additional information submitted in support of your request.

Level 2: Independent Review Entity (IRE)

If we uphold our denial, your appeal does not move forward automatically. You, your prescriber, or your authorized representative may ask the Independent Review Entity (IRE) — an independent organization not affiliated with Elderplan — to review the decision. You must request this review within 65 calendar days of the date on our redetermination notice. Your notice will explain how to request it.

Additional Appeal Levels

Depending on the circumstances and applicable Medicare requirements, additional levels of appeal may be available.

These may include:

• Office of Medicare Hearings and Appeals (OMHA) 
• Medicare Appeals Council (MAC) 
• Federal District Court 

Information about additional appeal rights will be included in your appeal decision notices.

Filing a Complaint (Grievance)

A complaint, also called a grievance, is different from an appeal.

You file an appeal when you disagree with a coverage decision.

You file a grievance when you have concerns about the quality of care you received, customer service, or the way your prescription drug benefit is being administered.

Examples include:

• Difficulty reaching Member Services 
• Problems obtaining information about your coverage 
• Concerns about customer service 
• Concerns about how your request was handled 
• Concerns about delays in processing your request 

You may file a grievance by contacting Member Services.

Appointing a Representative

You have the right to appoint a family member, friend, attorney, physician, or another individual to act on your behalf during the coverage determination or appeals process.

An Appointment of Representative form may be required.

Need an Exception?

If your medication is not on the formulary, is placed in a higher-cost tier, or is subject to a coverage rule that may not be appropriate for your situation, you may be able to request an exception.

Learn more about formulary exceptions and tiering exceptions.

Need Help?

If you have questions about prescription drug coverage, coverage determinations, appeals, or exception requests, Member Services can help.