Medicare Part D: Coverage Decisions And Appeals

Coverage Decisions: Senior Health Plan makes a coverage decisions about your Part D prescription drug, or about paying for a Part D prescription drug you have already received.

Part D coverage decisions

As discussed in Section 4 of chapter 9 of the 2017 Evidence of Coverage, a coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your drugs.

Here are examples of coverage decisions you ask us to make about your Part D drugs:

  • You ask us to make an exception, including:
    • Asking us to cover a Part D drug that is not on the plan's List of Covered Drugs (Formulary)
    • Asking us to waive a restriction on the plan's coverage for a drug (such as limits on the amount of the drug you can get)
    • Asking to pay a lower cost-sharing amount for a covered non-preferred drug
  • You ask us whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on the plan's List of Covered Drugs (Formulary) but we require you to get approval from us before we will cover it for you.)
    • Please note: If your pharmacy tells you that your prescription cannot be filled as written, you will get a written notice explaining how to contact us to ask for a coverage decision.
  • You ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment.

If you disagree with a coverage decision we have made, you can appeal our decision.


What is an exception?

If a drug is not covered in the way you would like it to be covered, you can ask us to make an "exception." An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request. Here are three examples of exceptions that you or your doctor or other prescriber can ask us to make:

  1. Covering a Part D drug for you that is not on our plan's List of Covered Drugs (Formulary). (We call it the "Drug List" for short.)
    • If we agree to make an exception and cover a drug that is not on the Drug List, you will need to pay the cost-sharing amount that applies to drugs in Tier 4. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug.
  2. Removing a restriction on our coverage for a covered drug. There are extra rules or restrictions that apply to certain drugs on our List of Covered Drugs (Formulary) (for more information, go to Chapter 5 of the 2017 Evidence of Coverage and look for Section 4).
    • The extra rules and restrictions on coverage for certain drugs include:
      • Getting plan approval in advance before we will agree to cover the drug for you. (This is sometimes called "prior authorization.")
      • Being required to try a different drug first before we will agree to cover the drug you are asking for. (This is sometimes called "step therapy.")
      • Quantity limits. For some drugs, there are restrictions on the amount of the drug you can have.
    • If we agree to make an exception and waive a restriction for you, you can ask for an exception to the copayment or co-insurance amount we require you to pay for the drug.
  3. Changing coverage of a drug to a lower cost-sharing tier. Every drug on the plan's Drug List is in one of 6 cost-sharing tiers. In general, the lower the cost-sharing tier number, the less you will pay as your share of the cost of the drug.
    • If your drug is in Tier 5 and is a brand name you can ask us to cover it at the cost-sharing amount that applies to drugs in Tier 3. This would lower your share of the cost for the drug.
    • If your drug is in Tier 5 and is a generic drug you can ask us to cover it at the cost sharing amount that applies to drugs in Tier 2. This would lower your share of the cost for the drug.
    • If your drug is in Tier 4 and is a brand name drug you can ask us to cover it at the cost-sharing amount that applies to drugs in Tier 3. This would lower your share of the cost for the drug.
    • If your drug is in Tier 4 and is a generic drug you can ask us to cover it at the cost-sharing amount that applies to drugs in Tier 2. This would lower your share of the cost for the drug.
    • You cannot ask us to change the cost-sharing tier for any drug in Tier 5.

Important things to know about asking for exceptions

Your doctor must tell us the medical reasons

Your doctor or other prescriber must give us a statement that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception.

Typically, our Drug List includes more than one drug for treating a particular condition. These different possibilities are called "alternative" drugs. If an alternative drug would be just as effective as the drug you are requesting and would not cause more side effects or other health problems, we will generally not approve your request for an exception.

We can say yes or no to your request
  • If we approve your request for an exception, our approval usually is valid until the end of the plan year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.
  • If we say no to your request for an exception, you can ask for a review of our decision by making an appeal. Chapter 9, Section 6.5 of the 2017 Evidence of Coverage tells how to make an appeal if we say no.

The next section tells you how to ask for a coverage decision, including an exception.


How to ask for a coverage decision, including an exception

Step 1:

You ask us to make a coverage decision about the drug(s) or payment you need. If your health requires a quick response, you must ask us to make a "fast coverage decision." You cannot ask for a fast coverage decision if you are asking us to pay you back for a drug you already bought.

What to do

  • Request the type of coverage decision you want. Start by calling, writing, or faxing us to make your request. You, your representative, or your doctor (or other prescriber) can do this. For the details, go to Chapter 2 , Section 1 of the 2017 Evidence of Coverage and look for the section called, How to contact us when you are asking for a coverage decision about your Part D prescription drugs. Or if you are asking us to pay you back for a drug, go to the section called, Where to send a request that asks us to pay for our share of the cost for medical care or a drug you have received.
  • You or your doctor or someone else who is acting on your behalf can ask for a coverage decision. Chapter 9, Section 4 of the 2017 Evidence of Coverage tells how you can give written permission to someone else to act as your representative. You can also have a lawyer act on your behalf.
  • If you want to ask us to pay you back for a drug, start by reading Chapter 7 of the 2017 Evidence of Coverage: Asking the plan to pay its share of a bill you have received for medical services or drugs. Chapter 7 of the 2017 Evidence of Coverage describes the situations in which you may need to ask for reimbursement. It also tells how to send us the paperwork that asks us to pay you back for our share of the cost of a drug you have paid for.
  • If you are requesting an exception, provide the "supporting statement." Your doctor or other prescriber must give us the medical reasons for the drug exception you are requesting. (We call this the "supporting statement.") Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone and follow up by faxing or mailing the signed statement. See Chapter 9, Sections 6.2 and 6.3 of the 2017 Evidence of Coverage for more information about exception requests.
  • We must accept any written request, including a request submitted on the CMS Model Coverage Determination Request Form which is available on our website.

If your health requires it, ask us to give you a "fast coverage decision"

  • When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "fast" deadlines. A standard coverage decision means we will give you an answer within 72 hours after we receive your doctor's statement. A fast coverage decision means we will answer within 24 hours after we receive your doctor's statement.
  • To get a fast coverage decision, you must meet two requirements:
    • You can get a fast coverage decision only if you are asking for a drug you have not yet received. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.)
    • You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.
  • If your doctor or other prescriber tells us that your health requires a "fast coverage decision," we will automatically agree to give you a fast coverage decision.
  • If you ask for a fast decision on your own (without your doctor's or other prescriber's support), we will decide whether your health requires that we give you a fast coverage decision.
    • If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will send you a letter that says so (and we will use the standard deadlines instead).
    • This letter will tell you that if your doctor or other prescriber asks for the fast coverage decision, we will automatically give a fast coverage decision.
    • The letter will also tell how you can file a complaint about our decision to give you a standard coverage decision instead of the fast coverage decision you requested. It tells how to file a "fast" complaint, which means you would get our answer to your complaint within 24 hours of receiving the complaint. (The process for making a complaint is different from the process for coverage decisions and appeals. For more information about the process for making complaints, see Chapter 9, Section 10 of the 2017 Evidence of Coverage.)
Step 2:

We consider your request and we give you our answer.

Deadlines for a "fast coverage decision"

  • If we are using the fast deadlines, we must give you our answer within 24 hours.
    • Generally, this means within 24 hours after we receive your request. If you are requesting an exception, we will give you our answer within 24 hours after we receive your doctor's statement supporting your request. We will give you our answer sooner if your health requires us to.
    • If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent outside organization. Later in this section, we talk about this review organization and explain what happens at Appeal Level 2.
  • If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 24 hours after we receive your request or doctor's statement supporting your request.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how to appeal.

Deadlines for a "standard coverage decision" about a drug you have not yet received

  • If we are using the standard deadlines, we must give you our answer within 72 hours.
    • Generally, this means within 72 hours after we receive your request. If you are requesting an exception, we will give you our answer within 72 hours after we receive your doctor's statement supporting your request. We will give you our answer sooner if your health requires us to.
    • If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization. Later in this section, we talk about this review organization and explain what happens at Appeal Level 2.
  • If our answer is yes to part or all of what you requested -
    • If we approve your request for coverage, we must provide the coverage we have agreed to provide within 72 hours after we receive your request or doctor's statement supporting your request.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how to appeal.

Deadlines for a "standard coverage decision" about payment for a drug you have already bought

  • We must give you our answer within 14 calendar days after we receive your request.
    • If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization. Later in this section, we talk about this review organization and explain what happens at Appeal Level 2.
  • If our answer is yes to part or all of what you requested, we are also required to make payment to you within 14 calendar days after we receive your request.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how to appeal.
Step 3:

If we say no to your coverage request, you decide if you want to make an appeal.

  • If we say no, you have the right to request an appeal. Requesting an appeal means asking us to reconsider - and possibly change - the decision we made.

How to make a Level 1 Appeal

(how to ask for a review of a coverage decision made by our plan)

An appeal to the plan about a Part D drug coverage decision is called a plan "redetermination."

Step 1:

You contact us and make your Level 1 Appeal. If your health requires a quick response, you must ask for a "fast appeal."

What to do

  • To start your appeal, you (or your representative or your doctor or other prescriber) must contact us.
    • For details on how to reach us by phone, fax, or mail for any purpose related to your appeal, go to Chapter 2, Section 1, of the 2017 Evidence of Coverage and look for the section called, How to contact us when you are making an appeal about your Part D prescription drugs.
  • If you are asking for a standard appeal, make your appeal by submitting a written request.
  • If you are asking for a fast appeal, you may make your appeal in writing or you may call us at the phone number shown in Chapter 2, Section 1 of the 2017 Evidence of Coverage, How to contact us when you are making an appeal about your part D prescription drugs.
  • We must accept any written request, including a request submitted on the CMS Model Coverage Determination Request Form, which is available on our website.
  • You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of good cause for missing the deadline may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.
  • You can ask for a copy of the information in your appeal and add more information.
    • You have the right to ask us for a copy of the information regarding your appeal. We are allowed to charge a fee for copying and sending this information to you.
    • If you wish, you and your doctor or other prescriber may give us additional information to support your appeal.

If your health requires it, ask for a "fast appeal"

  • If you are appealing a decision we made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a "fast appeal."
  • The requirements for getting a "fast appeal" are the same as those for getting a "fast coverage decision" in Section 6.4 of Chapter 9 of the 2017 Evidence of Coverage.
Step 2:

We consider your appeal and we give you our answer.

  • When we are reviewing your appeal, we take another careful look at all of the information about your coverage request. We check to see if we were following all the rules when we said no to your request. We may contact you or your doctor or other prescriber to get more information.

Deadlines for a "fast appeal"

  • If we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it.
    • If we do not give you an answer within 72 hours, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization. Later in this section, we talk about this review organization and explain what happens at Level 2 of the appeals process.
  • If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 72 hours after we receive your appeal.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no and how to appeal our decision.

Deadlines for a "standard appeal"

  • If we are using the standard deadlines, we must give you our answer within 7 calendar days after we receive your appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so. If you believe your health requires it, you should ask for a "fast" appeal.
    • If we do not give you a decision within 7 calendar days, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization. Later in this section, we talk about this review organization and explain what happens at Level 2 of the appeals process.
  • If our answer is yes to part or all of what you requested -
    • If we approve a request for coverage, we must provide the coverage we have agreed to provide as quickly as your health requires, but no later than 7 calendar days after we receive your appeal.
    • If we approve a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive your appeal request.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no and how to appeal our decision.
Step 3:

If we say no to your appeal, you decide if you want to continue with the appeals process and make another appeal.

  • If we say no to your appeal, you then choose whether to accept this decision or continue by making another appeal.
  • If you decide to make another appeal, it means your appeal is going on to Level 2 of the appeals process (see below).

How to make a Level 2 Appeal

If we say no to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Organization reviews the decision we made when we said no to your first appeal. This organization decides whether the decision we made should be changed.

Step 1:

To make a Level 2 Appeal, you (or your representative or your doctor or other prescriber) must contact the Independent Review Organization and ask for a review of your case.

  • If we say no to your Level 1 Appeal, the written notice we send you will include instructions on how to make a Level 2 Appeal with the Independent Review Organization. These instructions will tell who can make this Level 2 Appeal, what deadlines you must follow, and how to reach the review organization.
  • When you make an appeal to the Independent Review Organization, we will send the information we have about your appeal to this organization. This information is called your "case file." You have the right to ask us for a copy of your case file. We are allowed to charge you a fee for copying and sending this information to you.
  • You have a right to give the Independent Review Organization additional information to support your appeal.
Step 2:

The Independent Review Organization does a review of your appeal and gives you an answer.

  • The Independent Review Organization is an independent organization that is hired by Medicare. This organization is not connected with us and it is not a government agency. This organization is a company chosen by Medicare to review our decisions about your Part D benefits with us.
  • Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal. The organization will tell you its decision in writing and explain the reasons for it.

Deadlines for "fast" appeal at Level 2

  • If your health requires it, ask the Independent Review Organization for a "fast appeal."
  • If the review organization agrees to give you a "fast appeal," the review organization must give you an answer to your Level 2 Appeal within 72 hours after it receives your appeal request.
  • If the Independent Review Organization says yes to part or all of what you requested, we must provide the drug coverage that was approved by the review organization within 24 hours after we receive the decision from the review organization.

Deadlines for "standard" appeal at Level 2

  • If you have a standard appeal at Level 2, the review organization must give you an answer to your Level 2 Appeal within 7 calendar days after it receives your appeal.
  • If the Independent Review Organization says yes to part or all of what you requested -
    • If the Independent Review Organization approves a request for coverage, we must provide the drug coverage that was approved by the review organization within 72 hours after we receive the decision from the review organization.
    • If the Independent Review Organization approves a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive the decision from the review organization.

What if the review organization says no to your appeal?

If this organization says no to your appeal, it means the organization agrees with our decision not to approve your request. (This is called "upholding the decision." It is also called "turning down your appeal.")

If the Independent Review Organization "upholds the decision" you have the right to a Level 3 appeal. However, to make another appeal at Level 3, the dollar value of the drug coverage you are requesting must meet a minimum amount. If the dollar value of the coverage you are requesting is too low, you cannot make another appeal and the decision at Level 2 is final. The notice you get from the Independent Review Organization will tell you the dollar value that must be in dispute to continue with appeals process.

Step 3:

If the dollar value of the coverage you are requesting meets the requirement, you choose whether you want to take your appeal further.

  • There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal).
  • If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal. If you decide to make a third appeal, the details on how to do this are in the written notice you got after your second appeal.
  • The Level 3 Appeal is handled by an administrative law judge. Chapter 9, Section 9 of the 2017 Evidence of Coverage tells more about Levels 3, 4, and 5 of the appeals process.

Levels of Appeal 3, 4, and 5 for Part D Drug Appeals

This section may be appropriate for you if you have made a Level 1 Appeal and a Level 2 Appeal, and both of your appeals have been turned down.

If the value of the drug you have appealed meets certain dollar amount, you may be able to go on to additional levels of appeal. If the amount is less, you cannot appeal any further. The written response you receive to your Level 2 Appeal will explain who to contact and what to do to ask for a Level 3 Appeal.

For most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who handles the review of your appeal at each of these levels.


Level 3 Appeal

A judge who works for the Federal government will review your appeal and give you an answer. This judge is called an "Administrative Law Judge."

  • If the answer is yes, the appeals process is over. What you asked for in the appeal has been approved. We must authorize or provide the drug coverage that was approved by the Administrative Law Judge with in 72 hours (24 hours for expedited appeals) or make payment no later than 30 calendar days after we receive the decision.
  • If the answer is no, the appeals process may or may not be over.
    • If you decide to accept this decision that turns down your appeal, the appeals process is over.
    • If you do not want to accept the decision, you can continue to the next level of the review process. If the administrative law judge says no to your appeal, the notice you get will tell you what to do next if you choose to continue with your appeal.

Level 4 Appeal

The Appeals Council will review your appeal and give you an answer. The Appeals Council works for the Federal government.

  • If the answer is yes, the appeals process is over. What you asked for in the appeal has been approved. We must authorize or provide the drug coverage that was approved by the Appeals Council with in 72 hours (24 hours for expedited appeals) or make payment no later than 30 calendar days after we receive the decision.
  • If the answer is no, the appeals process may or may not be over.
    • If you decide to accept this decision that turns down your appeal, the appeals process is over.
    • If you do not want to accept the decision, you might be able to continue to the next level of the review process. If the Appeals Council says no to your appeal, or denies your request to review the appeal, the notice you get will tell you whether the rules allow you to go on to Level 5 appeal. If the rules allow you to go on, the written notice will also tell you who to contact and what to do next if you choose to continue with your appeal.

Level 5 Appeal

A judge at the Federal District Court will review your appeal. This is the last step of the appeals process.

Disclaimers

  • You may join or leave a plan only at certain times. Please call Senior Health Plan at the telephone number listed in the previous section of this web page or 1-800-MEDICARE (1-800-633-4227) for more information. TTY users should call 1-877-486-2048. You can call this number 24 hours a day, seven days a week.
  • You can join Senior Health Plan if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, individuals with End Stage Renal Disease are generally not eligible to enroll in Senior Health Plan unless they are members of our organization and have been since their dialysis began.
  • Senior Health Plan has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. You can ask for a current Provider Directory for an up-to-date list or search the Senior Health Plan provider directory on this website. If you choose to go to a doctor outside of our network, you must pay for these services yourself. Neither Senior Health Plan nor Original Medicare will pay for these services.
  • You must continue to pay your Medicare Part B premium, even if the Senior Health Plan premium is $0.