What's the best way to appeal a medication decision made by Medicare?

1 answer | Last updated: Oct 17, 2016
A fellow caregiver asked...

My friend is disabled and receiving MediCal and Medicare. She initially was on MediCal and recently received Medicare because her father started to receive SS payments. Recently, Medicare sent her letters rejecting some medication, stating that it was not authorized for her particular condition. What is the best way to appeal this decision?

Expert Answers

Outpatient prescription drugs are covered by Medicare through a Part D prescription drug plan issued by a private insurance company. So, your friend would have been notified by that insurance company. Normally, it is a doctor's decision whether to prescribe a specific drug for a particular medical condition. But some drugs that doctors prescribe for a condition, and that patients find very useful, are not approved for use for that condition. If that happens, the Medicare Part D insurance plan can refuse to cover the drug (even though the prescription itself is perfectly legal). Or, in your friend's case, it may be that the particular drug is not on her Medicare Part D plan's "formulary," the specific list of drugs that Medicare Part D plan covers.

In either case, there is a formal appeal process she can follow to try to get the drug covered by her Medicare Part D insurance plan. Assistance from her doctor will be critical, to provide medical records or write a letter explaining why the medicine should be covered. The appeal process looks like this:

"¢ Coverage Determination. Her first step is to request a Coverage Determination by the plan. Her doctor will have to explain to the plan why she needs the particular medicine for her condition. The plan is supposed to reply within 72 hours. "¢ Redetermination by Plan. If she is turned down again by the plan, she has 60 days to file a written request for redetermination by the plan. The plan decides in 7 days. "¢ Independent Review. If the redetermination goes against her, she has 60 days to request a review by an Independent Review Entity (IRE) who does not work for the insurance company. The IRE decides within 7 days, within 72 hours.

If your friend hasn't succeeded with the IRE, she can appeal her claim to an administrative law judge. And if that doesn't work, she can appeal all the way to a review by the national Medicare Appeals Council, and even file a lawsuit in federal court (if her claim involves thousands of dollars worth of medicine).

For more detailed information about the appeal process, you and she can look at Section 5 of the official Medicare online pamphlet Your Medicare Rights and Protections [http://www.medicare.gov/Publications/Pubs/pdf/10112.pdf]. Also, your friend can get free, expert assistance with her appeal from a local office of the Health Insurance Counseling and Advocacy Program (HICAP); to find the local office nearest her, she can contact her state HICAP office.