FAQs: Medicare Part D Appeals

» View Medicare Part D Reimbursement Appeals Process

1. What is Medicare Part D? Click For Answer
   • Medicare Part D is a voluntary prescription drug benefit plan for Medicare beneficiaries. The plans are administered by private contractors and are either stand-alone prescription drug plans (PDPs) or a part of a Medicare Advantage plan (MA-PD).¹
   • Please visit the Medicare PDP Home Page or call 1-800-MEDICARE
     (1-800-633-4227) for a list of plans that are available in the beneficiary's home region.
2. How can Medicare beneficiaries enroll in a Medicare Part D Plan? Click For Answer
   • They can enroll online at www.medicare.gov, by calling the plan directly, or by calling Medicare at 1-800-MEDICARE (1-800-633-4227), where Medicare representatives will help them enroll.¹
3. What if the patient's Medicare Part D Plan won't cover a prescription drug?² Click For Answer
   • If the Medicare prescription drug plan won't cover a prescription drug that is prescribed, or if it will only cover the drug as a non-formulary item
     • Patients or healthcare providers may initiate a prior authorization or coverage determination request to seek coverage for the drug or a formulary benefit level. A coverage determination request could be known as a formulary exception request
     • Example: Request a coverage determination if the patient's plan requires the pharmacy to substitute another drug for the prescribed drug and the physician is not in agreement or if the patient disagrees with limits that have been placed upon the dispensing quantity (“Days Supply”) or dose quantity (drug units per dose) of the prescribed drug
4. Does the Program provide assistance to Sprycel (dasatinib) patients who enrolled in a Medicare Part D Plan and are unable to afford the cost of their Sprycel? Click For Answer
   • The Sprycel program does not provide assistance for out-of-pocket costs, such as co-pays or deductibles
   • Please contact Destination Access for more information: 1-800-861-0048
5. How do I request a redetermination? Click For Answer
   • View Medicare Appeals Process Overview
   • Redetermination requests must be filed no later than 60 days after receiving a denial to a coverage determination request. An expedited request can be made orally or in writing. Review the patient's Evidence of Coverage to determine if standard requests should be made orally or in writing.³
6. How is a redetermination request processed by the plan? Click For Answer
   • Once the redetermination request is received by the prescription drug plan, a decision must be made on the request within seven days for a standard request and 72 hours for an expedited request. If the decision is favorable, evidence of the approval will be sent to the pharmacy benefits manager indicating that the prescription will be covered. If the decision is unfavorable, you may file a request for a Level 2 appeal, known as a reconsideration.³
7. What if a Medicare beneficiary has a complaint about his/her plan? Click For Answer
   • If a Medicare beneficiary has a complaint about his/her Medicare prescription drug plan, and the complaint does not involve a coverage matter or payment for a covered drug, the beneficiary may file a “grievance.” Such grievances may include disagreement with customer service hours of operation, prescription waiting time, a dispute regarding cost-sharing expense,* etc. A grievance must be filed within 60 days of the event that led to a complaint.⁴
   • *If a patient believes he/she was charged too much for a prescription, call the company offering your plan to get the most up-to-date information regarding cost-sharing expense. If the plan does not adequately address the complaint, call 1-800-MEDICARE (1-800-633-4227).
8. What is Medicare Part D Low-Income Subsidy (LIS)? Click For Answer
   • The Social Security Administration (SSA) provides the Low-Income Subsidy benefit (LIS) for eligible Medicare Part D beneficiaries. Eligibility criteria for LIS are based upon household income and assets. LIS may make payments to assist a beneficiary with Medicare Part D Prescription Drug Plan expenses, including premiums, and cost-sharing expenses (co-pays, “Donut Hole,” etc).⁵
   • For further information on eligibility criteria or to apply for assistance, you may contact www.ssa.gov/prescriptionhelp/ or your local Social Security Administration office. To find your local office, you can visit www.ssa.gov/locator or call 1-800-772-1213.