SPRYCEL® (dasatinib) Medicare Part D Appeals
Medicare has a drug benefit program known as “Medicare Part D” for Medicare patients that is offered exclusively through private health insurance companies. Medicare advocates are available to assist beneficiaries with appeals processes; however, the appeal should be managed carefully to ensure it is properly prepared and health insurer time requirements are met.
There are currently five levels of appeal in the Medicare Part D program1:
- Level 1: Redetermination
- Level 2: Reconsideration
- Level 3: Administrative Law Judge (ALJ) Hearing
- Level 4: Medicare Appeals Council (MAC)
- Level 5: Federal District Court Hearing
Each level must be completed before the patient is eligible to advance to the next level of appeal. In addition, there are time and dollar thresholds that must be met.
The illustration below is an overview of the Medicare Part D appeal1 process. Each level of appeal should be managed carefully, as each has different timing requirements.
AIC = Amount In Controversy.
ALJ = Administrative Law Judge.
MA-PD = MediDirect-to-Patient Shipment Program plan that offers Part D benefits.
PDP = Prescription Drug Plan.
QIC = Qualified Independent Contractor.
*A request for a coverage determination includes a request for a tiering exception or a formulary exception. A request for a coverage determination may be filed by the enrollee, the enrollee’s appointed representative, or the enrollee’s physician.
To learn more about Medicare Part D Appeals, click here
†The adjudication time frames generally begin when the request is received by the plan sponsor. However, if the request involves an exception request, the adjudication time frame begins when the plan sponsor receives the physician’s supporting statement.
‡Starting in 2005, the AIC requirement for an ALJ hearing and Federal District Court will be adjusted in accordance with the medical care component of the consumer price index.
Reference:
1. Medicare Rights Center. Medicare Part D appeals. Available at: http://www.medicarerights.org. Accessed November, 2009.
729US09WA15201 12/09