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Frequently Asked Questions

Part D Enrollees & Representatives  /  Frequently Asked Questions

Enrollees & Representatives

Frequently Asked Questions

Question 1
Could my prescribing doctor help me with my reconsideration appeal?
Answer 1:
Yes, your prescribing doctor’s office may help you and they may request the reconsideration appeal. An Appointment of Representative (AOR) form is not needed if your prescribing doctor requests the reconsideration appeal on your behalf.

 

Question 2
Is there an advantage to having my prescribing doctor request the reconsideration appeal instead of me?
Answer 2:
The decision outcome is not affected by who requests a valid reconsideration appeal. A statement from your prescribing doctor may be needed to support an exception to the plan’s rules, regardless of who requests the appeal. The prescriber’s statement may be filed with us by either you or your prescribing doctor. We may contact your prescribing doctor to obtain any additional information that is needed to process your appeal.

 

Question 3
What information do I need to include when I request a drug benefit reconsideration appeal?
Answer 3:
You may request a standard or expedited (fast) appeal by sending a signed written request to us within 60 calendar days from the date of the notice of your plan’s redetermination, unless the time frame is extended by us for good cause. You may use the Reconsideration Request Form, but we will accept any other written document as long as it is signed and includes the following:

  1. Your full name
  2. Your Medicare Number
  3. Identification of the item that is being appealed, e.g., the prescription drug, including dose and quantity
  4. Name of the Part D plan that denied coverage
  5. A prescriber statement is required if you are requesting an exception to your plan’s formulary rules. Please ask your prescribing doctor to address the plan’s coverage criteria as stated in the plan’s denial letter and why the drug(s) required by the plan are not medically appropriate for you. If you or your prescribing doctor believe that waiting for a standard decision (which will be provided within seven calendar days) could seriously harm your life, health or ability to regain maximum function, you may ask for an expedited appeal by checking the box for it or having your prescribing doctor include “urgent” and “expedited” in the prescriber statement.

Reconsideration Request Form - Drug Benefit (PDF)

 

Question 4
Could my family member or friend help me with my reconsideration appeal?
Answer 4:
If you want someone other than yourself or your prescribing doctor to request the appeal on your behalf, they must be an authorized representative. They may request the appeal on your behalf using the Reconsideration Request Form, but we will accept any other written document as long as it is signed and includes the following:

  1. Your full name
  2. Your Medicare Number
  3. Identification of the item that is being appealed, e.g., the prescription drug, including dose and quantity
  4. Name of the Part D plan that denied coverage
  5. Representative’s full name and relationship to you
    They must attach documentation showing the authority to represent you (a completed Appointment of Representative (AOR) Form or a written equivalent) if it was not submitted at the coverage determination or redetermination level
  6. A prescriber statement is required if you are requesting an exception to your plan’s formulary rules. Please ask your prescribing doctor to address the plan’s coverage criteria as stated in the plan’s denial letter and why the drug(s) required by the plan are not medically appropriate for you. If you or your prescribing doctor believe that waiting for a standard decision (which will be provided within seven calendar days) could seriously harm your life, health or ability to regain maximum function, you may ask for an expedited appeal by checking the box for it or having your prescribing doctor include “urgent” and “expedited” in the prescriber statement

AOR Form

 

Question 5
How long will it take you to make a decision on my appeal? Is there a way to ask for a quicker decision?
Answer 5:
Decisions for a standard pre-service drug benefit appeal are generally mailed or faxed within seven calendar days. You may request an expedited appeal, if you or your prescribing doctor thinks delaying the decision could seriously harm your life, health or ability to regain maximum function. If your appeal requires an expedited decision, we will call you with a decision within 72 hours.

Decisions for a standard retrospective drug benefit appeal (request for reimbursement of a drug already received) are generally mailed or faxed within 14 calendar days.

Prescriber statements are required if you are requesting an exception to your plan’s formulary rules. If a prescriber statement is missing, we will request a statement from your prescribing doctor. Processing may take longer (generally up to 14 days) while we try to obtain this missing information.

 

Question 6
The denial from my plan states that the drug was being used for an off-label indication. What does this mean for me and my appeal?
Answer 6:
Medicare rules require that a drug be prescribed for indications that are supported in Medicare approved drug references. If you or your prescribing doctor believe that a drug prescribed should be covered to treat your condition, you may request a reconsideration appeal and we will make a case-by-case decision on it using the Medicare-approved references.

 

Question 7
Does Medicare Part D cover drugs that are compounded?
Answer 7:
This depends on the components or ingredients of the compounded drug. Each ingredient must meet Medicare rules to be eligible for coverage. Each ingredient must be a prescription drug that is approved by the Food and Drug Administration (FDA) and prescribed for an indication supported in the Medicare approved drug references. Many compounded drugs are made from bulk powders that are not FDA approved, and are not eligible for coverage under Medicare Part D.

 

Question 8
How can I find out if the drug prescribed to me may be covered for my condition?
Answer 8:
Medicare Part D does not cover certain drugs, classes of drugs or drugs prescribed for certain medical uses. The list below are drugs that are not covered; these are called “exclusions.” There are some exceptions to the list below:

  • Drugs used for anorexia, weight loss or weight gain
  • Drugs used to promote fertility
  • Drugs used for cosmetic purposes or hair growth
  • Drugs used to relieve symptoms of cough or cold
  • Prescription vitamins and mineral products (except prenatal vitamins and fluoride preparations)
  • Nonprescription drugs (drugs you buy over-the-counter)
  • Drugs subject to a manufacturer tying arrangement
  • Drugs used to treat sexual or erectile dysfunction

*Some plans may provide supplemental coverage for certain excluded drugs, as indicated in your benefits package.

 

Question 9
How do I appeal an Unfavorable or Partially Favorable reconsideration decision or dismissal?
Answer 9:
The reconsideration decision letter you receive from us will include steps on how to request an appeal at the next level of review, the Office of Medicare Hearings and Appeals (OMHA). If the reconsideration decision was Unfavorable or Partially Favorable, you or your representative may request for an Administrative Law Judge (ALJ) hearing. OMHA must receive the request within 60 calendar days after you received the reconsideration decision or dismissal that you are appealing.

Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal (PDF)

Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal (Large Print) (PDF)

 

Question 10
I received a favorable reconsideration decision that granted my request for an exception to my plan’s formulary. Am I going to have to request this exception every year from the plan?
Answer 10:
This depends on the plan and on the circumstances of your exception. The plan is generally required to continue covering the drug for the rest of the plan year. Your plan may require you to file a new exception request when the new plan year starts in January. Please contact your plan for further guidance on this issue.

 

Question 11
I received a favorable reconsideration decision that the plan needed to cover the drug prescribed to me. When I went to the pharmacy, I discovered that the plan is still denying coverage for the drug. What can I do?
Answer 11:
You should contact the plan first. If you still are not receiving coverage, you should contact 1-800-MEDICARE (1-800-633-4227).

 

Question 12
Does Medicare Part D cover drugs that have not been approved by the Food and Drug Administration (FDA)?
Answer 12:
No. In order for a drug to be eligible for coverage under the Medicare Part D, the drug must be:

  1. Approved by the FDA for safety and effectiveness;
  2. Available only by prescription (over-the-counter drugs are not covered);
  3. Used and sold in the United States; and
  4. Used for a medically accepted indication.

Search for FDA-approved drugs

 

Question 13
My plan gave me notice that I owe a penalty for enrolling late in the Medicare Prescription Drug Program. How do I appeal?
Answer 13:
If you are being charged a Late Enrollment Penalty (LEP), you may request an LEP reconsideration appeal. You may use the Reconsideration Request Form, but we will accept any other written document as long as it is signed and includes the following:

  1. Your full name
  2. Your Medicare Number
  3. Name of the Part D plan that denied coverage

Reconsideration Request Form - Late Enrollment Penalty (LEP) (PDF)

 

Question 14
Why was a Late Enrollment Penalty (LEP) added to my monthly premium?
Answer 14:
Your Part D plan and Medicare are responsible for determining LEP charges. If you did not have prior creditable prescription drug coverage when you were first eligible to enroll in Part D, and you went for 63 or more days without having such coverage, the Part D plan and Medicare will likely charge you an LEP. The Part D QIC processes LEP appeals to determine if the LEP charge is correct under Medicare rules. The Part D QIC is not responsible for administering LEP charges.

 

Question 15
I received a reconsideration decision letter telling me that I did not owe a Late Enrollment Penalty (LEP), but my plan is still charging me a penalty. What should I do?
Answer 15:
If more than 90 days have elapsed from the date of the LEP reconsideration letter and you are still being charged a LEP, you should contact 1-800-MEDICARE (1-800-633-4227). This number is listed on the LEP reconsideration letter. The Part D QIC cannot provide reimbursement or remove the LEP.

 

Question 16
I recently filed a Late Enrollment Penalty (LEP) appeal but I have not received a decision letter yet. How long will it take for a decision to be made?
Answer 16:
The Part D QIC has 90 days to make a decision on an LEP appeal. You will generally receive an LEP reconsideration letter within 90 days of submitting your request for a reconsideration appeal.

 

Question 17
I received a reconsideration decision letter telling me that I still owe a Late Enrollment Penalty (LEP). How do I appeal?
Answer 17:
The reconsideration decision issued by the Part D QIC for LEP appeals is final and not subject to further appeal. However, if you believe there was an error in the decision or you have new information that might change the decision that you did not have before, you may request a reopening. The reopening request must be received within 180 days of receipt of the Part D QIC’s Reconsideration decision.